The nurse and a client talk about the signs and symptoms of acute mania. The client states, "When I am feeling really good and don't need to sleep, I am manic, but the last thing I want is treatment
" The nurse recognizes that this experience is indicative of the need for: 1. Competency.
2. Psychiatric advance directive (PAD).
3. Right to treatment.
4. Informed consent.
2
Rationale: Psychiatric advance directives (PADs) are modeled after advance directives for end-of-life care. They are legal instruments that allow competent persons to document their preferences regarding mental health treatment. Any person can prepare a PAD as a contingency plan to put in place should the person be incapacitated, found to be incompetent, or unable to make reliable decisions about psychiatric care. Informed consent is the right to understand the treatment process prior to consenting to treatment. Being competent means that a client must be cognitively able to understand the situation and the implications of treatment. Right to treatment ensures that clients are not in a treatment setting for custodial purposes only.
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A patient with catatonic schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which nursing intervention should receive the highest priority?
a. Conducting passive range-of-motion exercises b. Exposing the patient to auditory and visual stimuli c. Interacting with the patient as if he is responding d. Including the patient in a variety of milieu activities
The nurse is caring for a client who is experiencing discomfort following a tongue piercing. Which instruction is most helpful?
A) Floss your teeth daily. B) Eat soft foods. C) Brush your teeth carefully. D) Rinse mouth with antibacterial mouthwash.
The client tells the nurse that everything "tastes funny" since starting a new medication, making eating unpleasant. The nurse has given this medication to other clients, and has not heard this complaint from any of them
The nurse re-checks the drug information resource to learn whether this is a known side effect of the medication, and reads that it is. This information may be helpful in making a nursing diagnosis and in determining how best to address this problem. Subjective data for this client includes: 1. The client tells the nurse that, since starting a new medication, everything "tastes funny.". 2. The nurse has never experienced other clients who have taken this medication report this. 3. The nurse re-checks the drug reference to learn whether this is a known side effect of the medication. 4. The nurse reads that this medication can cause a metallic taste in some clients.
The nurse who assesses a hematoma behind a client's left ear over the mastoid bone would document this finding as being:
1. normal. 2. Battle's sign. 3. caused by sun exposure. 4. perichondritis.