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?

“I’d like to hear your thoughts about giving yourself this medication.”

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

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

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

Answer and Explanation

The Correct Answer is A

A. “I’d like to hear your thoughts about giving yourself this medication.”: This response uses open-ended, therapeutic communication that invites the client to express concerns, fears, or misconceptions. It demonstrates respect for autonomy and helps build trust while allowing the nurse to assess readiness to learn. Understanding the client’s perspective is essential before providing education or problem-solving.

B. “You will suffer serious health issues if you don't take your medication.”: This response uses fear and threats, which can increase anxiety and resistance rather than promote cooperation. It does not encourage dialogue or address the client’s underlying concerns.

C. “Why don't you want to learn how to give yourself your medication?”: Questions beginning with “why” can feel accusatory or judgmental, causing the client to become defensive. Although the nurse needs to understand the client’s reluctance, this phrasing may inhibit open communication. A more neutral approach is preferred.

D. “Have you considered how your decision to refuse medication will affect your family?”: This response applies guilt and shifts the focus away from the client’s feelings and autonomy. It does not promote therapeutic communication or support informed decision-making. Using guilt can undermine trust and collaboration.

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Correct Answer is A

Explanation

A. “When I sign the consent form, I am stating that the client appears to be competent to give consent.”: The nurse’s role in informed consent is to witness the client’s signature and verify that the client appears competent and is signing voluntarily. This demonstrates proper understanding of the nurse’s legal responsibility in the consent process.

B. “I will sign the consent form to indicate that the client has received written materials explaining the procedure.”: Providing written materials and explaining the procedure is the responsibility of the healthcare provider performing the procedure. The nurse does not sign the consent to verify that teaching has occurred.

C. “I will provide the client with an explanation of the procedure before I sign the consent form.”: Explaining the procedure, including risks and benefits, must be done by the provider who will perform it. The nurse may reinforce information but does not provide the primary explanation for consent.

D. “It is my responsibility to obtain informed consent from the client prior to the procedure.”: Obtaining informed consent is the legal responsibility of the provider performing the procedure. The nurse supports the process by witnessing the signature and ensuring consent is given voluntarily.

A. Raises all four side rails on the client's bed B. Locks the wheels on the client's bed C. Assists the client to the bathroom every 2 hr D. Clears furniture from the path leading to the bathroom

Correct Answer is A

Explanation

A. Raises all four side rails on the client's bed: Raising all four side rails can create a restraint situation, increasing the risk of entrapment or injury. Current safety guidelines recommend using only two side rails and employing other fall-prevention strategies instead.

B. Locks the wheels on the client's bed: This is a standard safety measure. Locking the wheels ensures the bed does not move when the client attempts to sit up or get out of bed, reducing fall risk. This is an appropriate safety measure for clients at risk for falls.

C. Assists the client to the bathroom every 2 hr: Regularly assisting the client to the bathroom reduces the likelihood of unassisted ambulation, which can prevent falls. Scheduled toileting is a recommended intervention for fall prevention.

D. Clears furniture from the path leading to the bathroom: Removing obstacles ensures a clear walking path and minimizes tripping hazards. Removing environmental hazards, such as clutter, loose rugs, or excess furniture, creates a clear, safe pathway for the client and reduces the risk of tripping.

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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

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