A client says to the nurse “I will not take the prescribed medication today.” What should be the initial action by the nurse?
Listen to the reason for refusal.
Report refusal to the charge nurse.
Explain the purpose of the medication.
Encourage the client to take the medication.
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
“I will discard unused pills after six months after replacing it with a new vial.” This statement indicates that the client understands that nitroglycerin tablets lose their potency over time and need to be replaced regularly.
Choice B is wrong because nitroglycerin can cause headaches as a side effect, but the client should not stop taking it if they have chest pain. They can use Tylenol for pain relief.
Choice C is wrong because nitroglycerin can cause hypotension and dizziness, so the client should avoid lying down or changing positions suddenly after taking it. They should sit or stand still until the chest pain subsides.
Choice D is wrong because a tingling feeling on the tongue is a normal sensation when taking sublingual nitroglycerin and does not indicate an adverse reaction. It also confirms that the tablet is potent and effective.
Correct Answer is D
Explanation
Diminished breath sounds in a client admitted with pneumonia. This is because diminished breath sounds indicate a worsening of the respiratory condition and a possible complication of pneumonia, such as atelectasis or pleural effusion.
The healthcare provider should be notified immediately to assess the client and order appropriate interventions.
Choice A is wrong because a report of joint pain by a client who recently started taking arthritis medication is not an urgent finding.
Joint pain is a common symptom of arthritis and may take some time to improve with medication.
The nurse should monitor the client’s pain level and administer analgesics as prescribed.
Choice B is wrong because report of decreased appetite and difficulty sleeping is not an immediate concern.
These are nonspecific symptoms that may be related to stress, anxiety, depression, or other factors.
The nurse should explore the possible causes of these symptoms and provide emotional support and education to the client.
Choice C is wrong because a weight loss of two pounds in a client admitted to congestive heart failure is not a critical finding.
Weight loss may indicate a reduction of fluid retention, which is a desired outcome for clients with heart failure.
The nurse should monitor the client’s weight daily and report any significant changes to the health care provider.
Normal ranges for weight, appetite, sleep, joint pain, and breath sounds vary depending on the individual’s age, gender, height, activity level, medical history, and other factors.
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