A nurse is caring for a client who has schizophrenia and is refusing to take a prescribed medication. Which of the following actions should the nurse take?

Remind the client that they have been refusing the medication for 5 days.

inform the client that their provider will contact them to discuss their refusal of the medication

Document the client's refusal in the medication administration record.

Notify the pharmacy about the client's refusal of the medication

Answer and Explanation

The Correct Answer is C

A. Remind the client that they have been refusing the medication for 5 days: Pointing out the duration of refusal may come across as confrontational and does not respect the client's right to refuse treatment. It can also damage the therapeutic relationship without addressing the underlying concerns about the medication.

B. Inform the client that their provider will contact them to discuss their refusal of the medication: While involving the provider may eventually be necessary, the immediate nursing action should be to document the refusal accurately. The nurse can then inform the provider if needed based on facility policy.

C. Document the client's refusal in the medication administration record: Clients have the legal right to refuse medication, and it is the nurse’s responsibility to document the refusal clearly and objectively. Accurate documentation ensures legal protection for the client and the healthcare team and maintains the integrity of the medical record.

D. Notify the pharmacy about the client's refusal of the medication: Notifying the pharmacy about a single medication refusal is unnecessary unless there are repeated refusals requiring a change in the medication order. The pharmacy’s role is not to manage client compliance but to dispense prescribed medications.

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Correct Answer is A

Explanation

A. Tachycardia: Tachycardia, or an increased heart rate, is a common manifestation of opioid withdrawal. Withdrawal stimulates the sympathetic nervous system, leading to symptoms like tachycardia, sweating, anxiety, and restlessness.

B. Miosis: Miosis, or pinpoint pupils, is associated with opioid intoxication, not withdrawal. During withdrawal, pupils are often dilated (mydriasis) rather than constricted.

C. Hypotension: Hypertension, not hypotension, is more commonly seen during opioid withdrawal due to increased sympathetic nervous system activity. Blood pressure tends to rise rather than fall during withdrawal episodes.

D. Sedation: Sedation is a sign of opioid intoxication rather than withdrawal. Clients experiencing withdrawal are more likely to display agitation, irritability, and insomnia rather than drowsiness or sedation.

A. Review the need for the indwelling urinary catheter daily B. Empty the drainage bag when it is half full C. Use soap and water to provide perineal care D. Place the drainage bag on the bed when transporting the client E. Encourage the client to drink 1000 ml of fluid daily F. Change the indwelling urinary catheter tubing every 3 days.

Correct Answer is ["A","C"]

Explanation

A. Review the need for the indwelling urinary catheter daily: Daily review of catheter necessity reduces the risk of catheter-associated urinary tract infections (CAUTIs). Prompt removal when no longer needed limits bacterial entry and colonization, which significantly lowers infection rates in hospitalized clients.

B. Empty the drainage bag when it is half full: The drainage bag should be emptied when it is about two-thirds full, not half full, to prevent backflow and reduce strain on the system. Emptying too early or too often increases the risk of introducing pathogens into the closed system.

C. Use soap and water to provide perineal care: Using soap and water for perineal hygiene maintains cleanliness and reduces bacterial colonization near the catheter site. Routine perineal care is a critical intervention to minimize the risk of ascending infections into the urinary tract.

D. Place the drainage bag on the bed when transporting the client: The drainage bag must remain below bladder level during transport to prevent backflow of urine into the bladder. Placing the bag on the bed risks contamination and promotes reflux of potentially infected urine.

E. Encourage the client to drink 1000 mL of fluid daily: Although hydration generally helps prevent UTIs, this client is on a strict 1000 mL fluid restriction due to heart failure. Encouraging more fluid intake could worsen fluid overload and does not align with current prescribed therapy.

F. Change the indwelling urinary catheter tubing every 3 days: Routine changing of catheter tubing is not recommended unless clinically indicated (e.g., contamination, obstruction, infection). Unnecessary manipulation increases the risk of introducing pathogens into the urinary system.

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A nurse is caring for a client who has schizophrenia and is refusing to take a prescribed medication. Which of the following actions should the nurse take?

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