A nurse in an inpatient mental health facility is caring for a client who has major depressive disorder and refuses to take her medication. Which of the following actions should the nurse take first?
Explain to the client the consequences of refusal.
Identify the reason for the client's refusal.
Document the client's refusal in the medical record.
Inform the provider of the client's refusal.
The Correct Answer is B
A. While explaining the consequences of refusal is important, it may not address the underlying reason for the refusal and should come after identifying the reason.
B. Identifying the reason for the client's refusal is the first step in addressing the issue and may help determine the appropriate intervention.
C. Documenting the client's refusal is important but should not be the first action taken without understanding the reason for the refusal.
D. Informing the provider of the client's refusal may be necessary, but it should come after identifying the reason for the refusal and attempting to address it.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.
A. Asymmetric lesions with variegated (multiple) colors are characteristic features of melanoma, a type of skin cancer. Asymmetry means one half of the lesion does not match the other half in size, shape, or color.
B. Scaly and red lesions may indicate other skin conditions such as eczema or psoriasis but are not specific to skin cancer.
C. Brown lesions with a wart-like texture may indicate seborrheic keratosis, a benign skin growth, rather than skin cancer.
D. Firm and rubbery lesions may indicate benign skin tumors such as fibromas or lipomas, rather than skin cancer.
Correct Answer is C
Explanation
A. Provide the client with a walker: While a walker may be used during ambulation, ensuring the client's physiological readiness for ambulation takes precedence.
B. Premedicate the client with the prescribed analgesic: While pain management is important for comfort during ambulation, premedication may not be necessary for all clients and should be based on individual assessment.
C. Obtain the client's vital signs and oximetry prior to ambulation: This intervention allows the nurse to assess the client's physiological status and ensure stability before initiating ambulation, reducing the risk of complications.
D. Reinforce the client's surgical dressing: While maintaining the integrity of the surgical
incision is important, reinforcing the dressing alone does not ensure the client's readiness for ambulation.
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