A client admitted to the coronary care unit with an inferior wall myocardial infarction is anxious, sweating, tachypneic, and reports midsternal chest discomfort and nausea.
Which nursing diagnosis is the priority?

This is because responding inappropriately to questions can indicate that the client has difficulty hearing or understanding what is being asked. According to, hearing loss makes communication with the outside world difficult, and can result in new or exaggerated symptoms that are mistakenly attributed to cognitive decline.

Choice A is wrong because speaking in a low voice does not necessarily imply hearing loss. It could be due to other factors such as shyness, anxiety, or vocal cord problems.

Choice B is wrong because refusing to answer questions does not necessarily imply hearing loss.

It could be due to other factors such as lack of interest, defiance, or distrust.

Choice D is wrong because looking away from persons while speaking does not necessarily imply hearing loss.

It could be due to other factors such as cultural norms, eye contact avoidance, or distraction.

This is the most therapeutic response because it shows respect for the client’s autonomy and allows the nurse to explore the client’s concerns and feelings about the medication.

It also helps to establish trust and rapport with the client. Choice B. Report refusal to the charge nurse.

This is wrong because it does not address the client’s immediate needs and may make the client feel ignored or dismissed.

Choice C. Explain the purpose of the medication.

This is wrong because it may sound like lecturing or persuading the client, which can increase resistance and hostility.

Choice D. Encourage the client to take the medication.

This is wrong because it does not acknowledge the client’s right to refuse treatment and may imply that the nurse knows better than the client what is best for them.