Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client on an acute care mental health unit who was involuntarily admitted for 72 hr. after attacking a neighbor.
To keep the client in the hospital when the initial time to hold the client expires, which of the following must be determined?
A. Whether the client is unable to make arrangements to stay with someone.
Factors such as the client's ability to make arrangements to stay with someone or financial capability to pay for medications are not relevant to the decision of whether to continue the hold.
B. Whether the client is financially incapable of paying for medications.
Factors such as the client's ability to make arrangements to stay with someone or financial capability to pay for medications are not relevant to the decision of whether to continue the hold.
C. Whether the client is in danger of harming herself or others.
Involuntary admission to a mental health unit is done when an individual poses a threat to themselves or others due to a mental health condition. The initial hold is usually for 72 hours, during which the client's condition is assessed and an appropriate treatment plan is developed. If the client is still deemed to be a danger to themselves or others after the initial hold, the healthcare provider may request an extension of the hold or seek a court order to continue treatment. In order to keep the client in the hospital, it must be determined that they continue to pose a threat to themselves or others.
D. Whether the client is unwilling to accept that treatment is needed.
Similarly, unwillingness to accept treatment is not the determining factor, as involuntary treatment can be provided to clients who do not recognize their need for treatment if they are deemed to be a danger to themselves or others.
This question is an excerpt from Nurse Dive's nursing test bank - Mental Health Chapter 1 - Proctored Exam 2. Take the full exam now
Full Explanation
Involuntary admission to a mental health unit is done when an individual poses a threat to themselves or others due to a mental health condition. The initial hold is usually for 72 hours, during which the client's condition is assessed and an appropriate treatment plan is developed. If the client is still deemed to be a danger to themselves or others after the initial hold, the healthcare provider may request an extension of the hold or seek a court order to continue treatment.
In order to keep the client in the hospital, it must be determined that they continue to pose a threat to themselves or others.
Factors such as the client's ability to make arrangements to stay with someone or financial capability to pay for medications are not relevant to the decision of whether to continue the hold.
Similarly, unwillingness to accept treatment is not the determining factor, as involuntary treatment can be provided to clients who do not recognize their need for treatment if they are deemed to be a danger to themselves or others.
Similar Questions
The nursing student is assigned a client to interview and is asked to practice the therapeutic communication techniques of stating the implied and making and observation about their behavior.
Which statement by the student nurse best describes the technique?
A. I noticed that you pace the halls, and you have a tense look on your face. I sense you are anxious about something.
This statement by the student nurse demonstrates the technique of stating the implied and seeing the client's behavior. The student nurse has observed the client pacing the halls and having a tense look on their face, which implies that the client may be feeling anxious. By stating this observation to the client, the student nurse is validating the client's experience and opening a dialogue about their feelings. This technique can help the client feel heard and understood and can facilitate a therapeutic relationship between the client and the nurse.
B. Can you tell me more about how you feel when you are arguing with your daughter?
Option B is an open-ended question that can encourage the client to share more about their feelings, but it does not demonstrate the technique of stating the implied and making an observation about the client's behavior.
C. You look angry.
Option C is a statement that may be perceived as judgmental or confrontational and does not demonstrate the technique of stating the implied and making an observation about the client's behavior.
D. I would like to talk with you about your plan of care.
Option D is a statement that is focused on the nurse's agenda rather than the client's needs and does not demonstrate the technique of stating the implied and seeing the client's behavior.
Full Explanation
This statement by the student nurse demonstrates the technique of stating the implied and seeing the client's behavior. The student nurse has observed the client pacing the halls and having a tense look on their face, which implies that the client may be feeling anxious. By stating this observation to the client, the student nurse is validating the client's experience and opening a dialogue about their feelings. This technique can help the client feel heard and understood and can facilitate a therapeutic relationship between the client and the nurse.
Option B is an open-ended question that can encourage the client to share more about their feelings, but it does not demonstrate the technique of stating the implied and making an observation about the client's behavior.
Option C is a statement that may be perceived as judgmental or confrontational and does not demonstrate the technique of stating the implied and making an observation about the client's behavior.
Option D is a statement that is focused on the nurse's agenda rather than the client's needs and does not demonstrate the technique of stating the implied and seeing the client's behavior.
An order written by the physician is reviewed by the nursing staff, and no one is familiar with the treatment instructions. A nurse who is recently hired knows that this treatment is covered by the states nurse practice act.
What is the nurses’ best course of action?
A. Call the physician to ask for clarification.
B. Check the states nurse practice act.
C. Refer to the facility’s policy and procedures to determine the course of action.
When faced with an unfamiliar treatment instruction, it is important for the nurse to consult the facility’s policies and procedures to determine the appropriate course of action. These policies and procedures provide guidance on how to carry out treatments safely and effectively and can help ensure that the patient receives the best possible care. While it may also be appropriate for the nurse to call the physician for clarification (a), check the state’s nurse practice act (b), or contact the nursing supervisor for approval (d), consulting the facility’s policies and procedures should be the first step in determining the appropriate course of action.
D. Contact the nursing supervisor for approval to carry out treatment.
Full Explanation
When faced with an unfamiliar treatment instruction, it is important for the nurse to consult the facility’s policies and procedures to determine the appropriate course of action. These policies and procedures provide guidance on how to carry out treatments safely and effectively and can help ensure that the patient receives the best possible care.
While it may also be appropriate for the nurse to call the physician for clarification (a), check the state’s nurse practice act (b), or contact the nursing supervisor for approval (d), consulting the facility’s policies and procedures should be the first step in determining the appropriate course of action.
The nurse’s ability to use therapeutic communication effectively in the mental health setting depends on:
A. How well the client communicates.
The client’s ability to communicate (a) is also important, but it is ultimately the nurse’s responsibility to use effective communication techniques to facilitate the therapeutic process.
B. The nurse’s understanding of mental health disorders.
C. The nurse’s ability to listen and observe the clients verbal and non-verbal messages.
The nurse’s ability to listen and observe the client’s verbal and non-verbal messages. Effective communication in the mental health setting requires the nurse to actively listen to the client and to pay close attention to their verbal and non-verbal cues. By doing so, the nurse can better understand the client’s needs and concerns and can provide appropriate support and guidance. While the nurse’s understanding of mental health disorders (b) and their relationship with the client (d) can also play a role in effective communication, the ability to listen and observe is a fundamental skill that is essential for effective therapeutic communication. The client’s ability to communicate (a) is also important, but it is ultimately the nurse’s responsibility to use effective communication techniques to facilitate the therapeutic process.
D. The nurse’s relationship with the client.
Full Explanation
The nurse’s ability to listen and observe the client’s verbal and non-verbal messages. Effective communication in the mental health setting requires the nurse to actively listen to the client and to pay close attention to their verbal and non-verbal cues. By doing so, the nurse can better understand the client’s needs and concerns and can provide appropriate support and guidance.
While the nurse’s understanding of mental health disorders (b) and their relationship with the client (d) can also play a role in effective communication, the ability to listen and observe is a fundamental skill that is essential for effective therapeutic communication. The client’s ability to communicate (a) is also important, but it is ultimately the nurse’s responsibility to use effective communication techniques to facilitate the therapeutic process.