unit 19
The nurse is caring for a client who is scheduled for electroconvulsive therapy (ECT). The nurse notes that an informed consent has not been obtained for the procedure. On review of the record, the nurse notes that the admission was an involuntary hospitalization. Based on this information, which determination does the nurse make regarding consent? An informed consent does not need to be obtained. 2. The health care provider will obtain the informed consent. 3. An informed consent should be obtained from the family. 4. An informed consent needs to be obtained from the client.
An informed consent needs to be obtained from the client. Rationale: Clients who are involuntarily admitted do not lose their right to informed consent. The informed consent needs to be obtained from the client. Options 1, 2, and 3 are incorrect.
The nurse is assigned to care for a client who is agitated. On entering the room, the client screams, "Why don't you just leave me alone?" The nurse should make which therapeutic response to the client? 1. "Don't yell at me." 2. "Why do you feel this way?" 3. "I am calling your health care provider!" 4. "I can see that you are upset. I'll be back in a few minutes to see how you are doing."
I can see that you are upset. I'll be back in a few minutes to see how you are doing." Rationale: Option 4, the correct option, gives the client space and personal control. Option 2 may place the client on the defensive and is not a facilitative technique. Option 1 is confrontational and nonfacilitative and imposes control by the nurse. Option 3 is belittling, does not include the client, and does not provide a clear sense of direction.
The registered nurse has written an outcome statement of "Client will feel less anxious by the end of session" for a client with generalized anxiety disorder. Which interventions should the licensed practical nurse use to assist this client in meeting this goal? Select all that apply. 1. Stay with the client. 2. Give detailed directions to the client. 3. Administer anxiolytics medications if prescribed. 4. Ensure the client is in an environment with little stimuli. 5. Refrain from speaking until the client's anxiety is decreased.
Stay with the client. Administer anxiolytics medications if prescribed. 4. Ensure the client is in an environment with little stimuli. Rationale: Interventions that assist the client in meeting the goal of decreased anxiety include staying with the client, speaking slowly and calmly, and using short simple sentences with brief directions. The nurse may also administer anxiolytic (antianxiety) medications as prescribed after the level of anxiety has been assessed and environmental stimuli should be decreased.
The nurse is assisting in preparing a plan of care for the client who will be seen in the mental health clinic for the first time. In preparing for the orientation phase of the therapeutic relationship, the nurse suggests addressing which issue? Behavioral change 2. Self-esteem in the client 3. Problem-solving skills in the client 4. The parameters of the relationship
The parameters of the relationship Rationale: During the orientation phase of the therapeutic nurse-client relationship, four issues must be addressed. These issues include the parameters of the relationship, the formal or informal contract, confidentiality, and termination of the relationship. Promoting problem-solving skills and self-esteem and facilitating behavioral change are issues of the working phase of the nurse-client relationship.
A client is receiving a daily dose of oral fluphenazine. The nurse should reinforce instructions to the client to practice which intervention to minimize common side effects of this medication? Monitor pulse daily. 2. Eat snacks at midmorning and bedtime. 3. Use hard, sour candy or sugarless gum. 4. Have blood pressure checked once a week.
Use hard, sour candy or sugarless gum. Rationale: Fluphenazine is classified as an antidepressant and a selective serotonin reuptake inhibitor. Dry mouth is a common side effect. Frequent mouth rinsing with water, sucking on hard candy, and chewing sugarless gum will alleviate this common side effect. Hypotension and hypertension are rare side effects of oral fluphenazine. Fluphenazine does not affect the pulse. Weight gain is a common side effect, and frequent snacks will worsen the problem.
The nurse is caring for a hospitalized client who has been taking clozapine (Clozaril) for the treatment of a schizophrenic disorder. Which laboratory study prescribed for the client should the nurse specifically review to monitor for an adverse effect associated with the use of this medication? Platelet count 2. Cholesterol level 3. White blood cell count 4. Blood urea nitrogen level
White blood cell count Rationale: Hematological reactions can occur in the client taking clozapine and include agranulocytosis and mild leukopenia. The white blood cell count should be checked before initiating treatment and should be monitored closely during the use of this medication. The client should also be monitored for signs indicating agranulocytosis, which may include sore throat, malaise, and fever. Options 1, 2, and 4 are unrelated to this medication.
