A nurse in an assisted-living facility is caring for a client who is in early stages of dementia. The client has been oriented to name and place and is usually cooperative. Which of the following nursing actions is appropriate if the client refuses to take morning medications?
Notify the charge nurse of the need for evaluation of the client's level of competence.
Ask the client to express her reasons for refusing the morning medications and document the event.
Crush the pills, if not contraindicated, and hide them the client's in applesauce.
Try to talk the client into adherence by telling her the possible implications of missing a dose.
The Correct Answer is B
A: While assessing competence might eventually be necessary, it should come after understanding the client's reasons for refusal.
B: This action respects the client’s autonomy and provides insights into her thinking or possible misconceptions that can be addressed.
C: Crushing pills without consent and hiding them in food is unethical and could be dangerous, as some medications are not meant to be crushed.
D: Trying to convince the client might be seen as coercive. Understanding her reasons first is a more patient-centered approach.
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Related Questions
Correct Answer is C
Explanation
A: This is coercive and inappropriate, potentially causing distress.
B: This does not address the client’s expressed feelings of fatigue and could feel dismissive.
C: This supportive approach helps the client engage in activity at her own pace, promoting participation without coercion.
D: This encourages avoidance, which may further reinforce depressive behaviors and social withdrawal.
Correct Answer is A
Explanation
A: Hallucinations involve perceiving something that isn't actually there, such as seeing snakes on the walls.
B: Delirium is a rapid onset of confusion typically resulting from a physical or mental illness but is not specific to hallucinations.
C: Delusions are false beliefs held despite evidence to the contrary.
D: Psychosis can involve hallucinations but is a broader term that encompasses severe mental disorders.
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