Nokea
A nurse is caring for a client who has major depressive disorder. After discussing the treatment with his partner, the client verbally agrees to electroconvulsive therapy (ECT) but will not sign the consent form. Which of the following actions should the nurse take?
- A. Request that the client’s partner sign the consent form
- B. Cancel the scheduled ECT procedure
- C. Proceed with the preparation for ECT based on implied consent
- D. Inform the client about the risks of refusing the ECT
Correct Answer: B
Rationale: The correct answer is B: Cancel the scheduled ECT procedure. The nurse must prioritize the autonomy and right to informed consent of the client. Since the client has verbally agreed but will not sign the consent form, it indicates uncertainty or potential coercion. Proceeding without proper documentation could lead to legal and ethical issues. Requesting the partner to sign (A) may not be ethically sound without the client's explicit consent. Proceeding based on implied consent (C) is risky and violates the client's autonomy. Informing the client about risks (D) is important but should not override the need for proper consent. Cancelling the procedure allows time for further discussion and ensures the client's best interest.
You may also like to solve these questions
A nurse is assisting with obtaining informed consent from a client who has been declared legally incompetent. Which of the following actions should the nurse take?
- A. Contact the facility social worker to obtain the consent
- B. Explain implied consent to the client’s family
- C. Request that the client’s guardian sign the consent
- D. Ask the charge nurse to obtain informed consent
Correct Answer: C
Rationale: The correct answer is C: Request that the client’s guardian sign the consent. This is appropriate because a legally incompetent individual requires a guardian to make decisions on their behalf. This ensures that the client's best interests are protected and that decisions are made by someone legally authorized to do so. Choice A is incorrect because social workers are not authorized to provide consent for legally incompetent individuals. Choice B is incorrect as implied consent is not applicable in this scenario. Choice D is incorrect as the charge nurse does not have the legal authority to obtain informed consent for a legally incompetent client.
A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom?
- A. Delusions
- B. Hallucinations
- C. Social withdrawal
- D. Agitation
Correct Answer: C
Rationale: The correct answer is C: Social withdrawal. Negative symptoms in schizophrenia involve a decrease or absence of normal functions. Social withdrawal is a classic negative symptom, as it reflects a reduction in social interactions and interest. Delusions (A) and hallucinations (B) are positive symptoms, characterized by the presence of abnormal behaviors. Agitation (D) is associated with agitation and restlessness, not with negative symptoms. In summary, social withdrawal is the correct answer because it aligns with the definition of negative symptoms in schizophrenia.
A nurse is caring for a client who has major depressive disorder and is prescribed sertraline. Which of the following instructions should the nurse provide?
- A. Take the medication at bedtime
- B. Expect results within 1 to 2 days
- C. Avoid consuming grapefruit juice
- D. Stop taking the medication once symptoms improve
Correct Answer: C
Rationale: The correct answer is C: Avoid consuming grapefruit juice. Grapefruit juice can interact with sertraline, leading to increased levels of the medication in the bloodstream, potentially causing side effects or toxicity. It is essential for the nurse to instruct the client to avoid grapefruit juice to ensure the safe and effective use of sertraline. Taking the medication at bedtime (choice A) is not specifically necessary for sertraline. Expecting results within 1 to 2 days (choice B) is incorrect as antidepressants like sertraline typically take weeks to show full effects. Stopping the medication once symptoms improve (choice D) can be dangerous as abruptly discontinuing an antidepressant can lead to withdrawal symptoms or a relapse of depression.
A nurse is planning care for a client who has a history of alcohol use disorder and is experiencing withdrawal. Which of the following interventions should the nurse include in the plan?
- A. Administer disulfiram
- B. Monitor for seizures
- C. Restrict fluid intake
- D. Provide a high-protein diet
Correct Answer: B
Rationale: The correct answer is B: Monitor for seizures. During alcohol withdrawal, clients are at risk for seizures due to central nervous system hyperexcitability. Monitoring for seizures allows for prompt intervention if they occur. Administering disulfiram (A) is used to deter alcohol consumption, not for withdrawal. Restricting fluid intake (C) can worsen dehydration, while providing a high-protein diet (D) is not a priority during alcohol withdrawal.
A nurse in an alcohol treatment facility is caring for a client who states 'my job is so stressful that the only way I can cope is to drink.' The nurse should recognize that the client is displaying which of the following defense mechanisms?
- A. Repression
- B. Rationalization
- C. Introjection
- D. Intellectualization
Correct Answer: B
Rationale: The correct answer is B: Rationalization. Rationalization is a defense mechanism where individuals justify their behaviors or feelings with logical reasoning or excuses. In this case, the client is justifying their drinking by attributing it to the stress of their job. This defense mechanism helps the individual avoid facing the real underlying issues causing their behavior.
Choice A: Repression involves pushing unwanted thoughts or feelings into the unconscious mind, which is not demonstrated by the client's statement.
Choice C: Introjection is the internalization of external beliefs or values, not applicable in this context.
Choice D: Intellectualization is the process of focusing on facts and logic to avoid dealing with emotions, which is not evident in the client's statement.