Nokea
A nurse is providing teaching for a client who has major depressive disorder and is seeking voluntary admission to an acute mental health facility. Which of the following statements should the nurse include?
- A. "You will give up your right to refuse antidepressant medications upon admission."
- B. "Your provider is required to notify your employer of your admission."
- C. "You will still need to give informed consent for treatments after admission."
- D. "You cannot leave the facility until your provider completes a discharge summary."
Correct Answer: C
Rationale: The correct answer is C: "You will still need to give informed consent for treatments after admission." This statement is important to include in teaching because even after being admitted to a mental health facility, the client retains the right to give informed consent for any treatments or interventions. It emphasizes the client's autonomy and involvement in decision-making regarding their care.
The other options are incorrect:
A: "You will give up your right to refuse antidepressant medications upon admission." This statement is incorrect as the client still has the right to refuse specific treatments even after admission.
B: "Your provider is required to notify your employer of your admission." This statement is incorrect as confidentiality laws protect the client's privacy and do not require notification to the employer.
D: "You cannot leave the facility until your provider completes a discharge summary." This statement is incorrect as the client has the right to leave the facility against medical advice, although there may be consequences or processes to follow.
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A nurse in a mental health clinic is attempting to develop a therapeutic relationship with a client. Which of the following actions should the nurse take?
- A. Set limits for the relationship
- B. Promote the use of transference by the client
- C. Instruct the client on how he should behave
- D. Engage in friendly interactions with the client
Correct Answer: A
Rationale: The correct answer is A: Set limits for the relationship. In a therapeutic relationship, setting boundaries and limits is crucial to establish a safe and professional environment. This helps the client understand the expectations and maintain appropriate behavior. By setting limits, the nurse can ensure a therapeutic focus and prevent any potential harm or misunderstandings.
Choice B (Promote the use of transference by the client) is incorrect because encouraging transference can lead to unrealistic expectations and hinder the therapeutic process. Choice C (Instruct the client on how he should behave) is incorrect as it undermines the client's autonomy and may create a power dynamic. Choice D (Engage in friendly interactions with the client) is incorrect as it blurs professional boundaries and may lead to a lack of objectivity.
A nurse is providing teaching for a client who has binge-eating disorder and is morbidly obese. The client has been prescribed orlistat. Which of the following statements indicates to the nurse that the client understands the teaching?
- A. "I will take my dose of orlistat every morning an hour before breakfast."
- B. "I will stop taking orlistat and call my doctor if my urine gets darker in color."
- C. "I will eat a no-fat diet to prevent side effects from the medication."
- D. "I will feel less hungry during meals while I am taking orlistat."
Correct Answer: B
Rationale: The correct answer is B: "I will stop taking orlistat and call my doctor if my urine gets darker in color." This statement indicates understanding because dark urine can be a sign of liver injury, a serious side effect of orlistat. The client recognizing this symptom and knowing to contact the doctor promptly demonstrates comprehension of the medication's potential risks.
A: "I will take my dose of orlistat every morning an hour before breakfast." - This statement does not indicate understanding of the medication's specific instructions.
C: "I will eat a no-fat diet to prevent side effects from the medication." - While a low-fat diet is recommended with orlistat, this statement does not address potential serious side effects.
D: "I will feel less hungry during meals while I am taking orlistat." - This statement does not address the medication's side effects or potential risks.
A nurse is providing teaching about confidentiality with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
- A. "The courts might require me to discuss confidential information."
- B. "I am required to provide confidential information to insurance companies."
- C. "If questioned during a police investigation, I am required to divulge confidential information."
- D. "I am legally allowed to discuss confidential information with the client's former therapist."
Correct Answer: A
Rationale: Confidentiality may be broken if required by law, such as with a court order.
A nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following assessments by the nurse is the highest priority?
- A. Determining if the client has psychotic thinking
- B. Asking the client to identify the cause of the crisis
- C. Identifying the client's coping skills
- D. Identifying the client's support systems
Correct Answer: A
Rationale: The correct answer is A: Determining if the client has psychotic thinking. This is the highest priority because it directly addresses the client's immediate safety and well-being. Psychotic thinking can pose a significant risk to the client and others, requiring prompt intervention. Asking the client to identify the cause of the crisis (B), identifying coping skills (C), and support systems (D) are important but secondary to ensuring the client's safety. It is crucial to address any potential psychotic thinking first before delving into other aspects of the assessment.
A nurse is admitting a client who is exhibiting manic behavior. The client reports recent personal stressors including the loss of her mother and a divorce. Which of the following is the priority nursing action?
- A. Identifying support systems.
- B. Assisting the client in identifying coping behaviors.
- C. Encouraging self-care.
- D. Preventing self-directed violence.
Correct Answer: D
Rationale: Safety is the priority for clients experiencing manic episodes, as they are at risk for self-harm.