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 D
Explanation
Levofloxacin (Levaquin) is a fluoroquinolone antibiotic that is not structurally related to penicillin and has a very low risk of cross-reactivity with penicillin.
Levofloxacin can be safely used in patients with penicillin allergy unless they have a history of hypersensitivity to other fluoroquinolones.
Choice A is wrong because cephalexin (Keflex) is a first-generation cephalosporin that has a similar side chain to some penicillins and may cause cross-reactivity in penicillin-allergic patients. The risk of cross-reactivity is higher for first- and second-generation cephalosporins than for third- and fourth-generation cephalosporins.
Choice B is wrong because cefaclor (Ceclor) is a second-generation cep
Correct Answer is ["A","B","C","D"]
Explanation
The correct answers are Choices A, B, C, and D.Choice A rationale:Inspection of lips and mucous membranes is a vital assessment technique for hydration status. Dryness or cracking of the lips and mucous membranes can indicate dehydration, as these areas are often affected by fluid loss. Observing these features helps healthcare providers assess the client's hydration level effectively.Choice B rationale:Pinching the skin on the back of the hand tests skin turgor, which is a reliable indicator of hydration status. If the skin does not return to its normal position quickly after being pinched, it suggests decreased skin elasticity due to dehydration. This method provides a quick visual and tactile assessment of fluid levels in the body.Choice C rationale:Measuring pulse and blood pressure is essential in evaluating hydration status. Changes in blood pressure (especially orthostatic hypotension) and pulse rate can indicate fluid volume changes in the body. An increased heart rate may suggest dehydration, while low blood pressure can indicate significant fluid loss.Choice D rationale:Obtaining the client's daily weight is a crucial method for monitoring hydration status. Weight fluctuations can provide insight into fluid retention or loss over time. A sudden decrease in weight may indicate dehydration, while an increase could suggest fluid overload or retention issues.Choice E rationale:Palpating scalp and hair distribution is not a common or effective method for assessing hydration status. While scalp condition may reflect overall health, it does not provide direct information about hydration levels compared to other methods listed.
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