A nurse is caring for a client who has a new diagnosis of diabetes mellitus and is refusing to learn how to self-administer insulin. Which of the following responses should the nurse make?

"Why don't you want to learn how to give yourself your medication?"

"You will suffer serious health issues if you don't take your medication."

"I'd like to hear your thoughts about giving yourself this medication."

"Have you considered how your decision to refuse medication will affect your family?"

Answer and Explanation

The Correct Answer is C

This response allows the nurse to express genuine interest in the client's perspective and opens up a dialogue to understand the client's concerns or reasons for refusing to learn how to self-administer insulin. It provides an opportunity for the client to express their fears, doubts, or any barriers they may have. By actively listening to the client, the nurse can better address their concerns and provide appropriate education and support tailored to their individual needs.

The other options may come across as confrontational, judgmental, or unhelpful in establishing a therapeutic relationship with the client. It is important for the nurse to approach the situation with empathy, respect, and a non-judgmental attitude to foster effective communication and promote the client's engagement in their own care.

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Correct Answer is B

Explanation

Informed consent is a process where the healthcare provider explains the risks, benefits, and alternatives of a proposed procedure or treatment to the client. The client then demonstrates their understanding of this information and voluntarily agrees to undergo the procedure or treatment.

A. "I will have a large scar on my stomach after this procedure". This is incorrect for a vaginal hysterectomy, which does not involve an abdominal incision.

B. 'I am thankful I am done having children." This statement reflects an understanding of a key consequence of a hysterectomy, which is the removal of the uterus and the resulting inability to have children. This indicates that the client is aware of and accepts the major impact of the surgery on their reproductive capabilities.

C."I should expect my periods to resume in 1 month.": This is incorrect because the removal of the uterus means the client will no longer have menstrual periods.

D."I will no longer need a regular gynecological examination.": This is incorrect because regular gynecological examinations are still necessary to monitor overall reproductive health and screen for other conditions.

A. "The psychiatric staff is not FBI. They are here to help you." B. "This must be very frightening for you. Let's talk more about it." C. "What makes you think the staff is following you?" D. "Why do You feel the staff is the FBI?"

Correct Answer is B

Explanation

The response acknowledges the client's feelings and validates their experience without reinforcing or denying the delusion. It demonstrates empathy and invites further exploration of the client's concerns. Open-ended statements like this can encourage the client to express their thoughts and feelings, allowing for therapeutic communication and building trust between the client and nurse.

"The psychiatric staff is not FBI. They are here to help you." This response directly contradicts the client's belief and may lead to increased distrust or resistance. It is important to avoid directly challenging delusions or imposing one's own reality on the client, as it can escalate their distress.

"What makes you think the staff is following you?" While this response seeks more information, it may inadvertently reinforce or amplify the client's delusion. It could be interpreted as confirmation or validation of their belief, potentially increasing anxiety or paranoia.

"Why do you feel the staff is the FBI?" This response also seeks more information, but it may come across as challenging or dismissive. It could potentially trigger defensiveness or hostility in the client. It is important to approach the client's beliefs with empathy and respect rather than questioning or interrogating them.

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A nurse is caring for a client who has a new diagnosis of diabetes mellitus and is refusing to learn how to self-administer insulin. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is verifying informed consent for a client who is preoperative for a vaginal hysterectomy. Which of the following statements should the nurse identify as an indication that the client has given informed consent?

Correct Answer is B

Explanation

A nurse is caring for a client who has paranoid schizophrenia and believes that they are being followed by FBI agents who are pretending to be psychiatric staff. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

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