An older adult male client, recently diagnosed with Type 2 diabetes, refuses to allow the practical nurse (PN) to stick his finger to obtain a blood glucose assessment, and states, "My fingers are sore and it's useless anyway. How should the PN document the refusal in the client's electronic medical record?
Healthcare provider notified, client refuses to have blood glucose taken.
Blood glucose not obtained because client no longer wants to have finger stick
Refused finger stick and states, "My finger is sore and test useless." Healthcare provider notified.
Healthcare provider notified that client is uncooperative and irritable, glucose level not assessed.
The Correct Answer is C
A. Healthcare provider notified, client refuses to have blood glucose taken: While this option indicates that the healthcare provider was informed and that the client refused, it does not fully capture the client’s expressed reason for refusal. Complete and precise documentation includes the client’s statement in their own words.
B. Blood glucose not obtained because client no longer wants to have finger stick: This phrasing is too casual and lacks the specificity needed for legal and clinical documentation. It does not reflect the client’s exact words or demonstrate that the healthcare provider was informed about the situation.
C. Refused finger stick and states, "My finger is sore and test useless." Healthcare provider notified: This option best meets documentation standards by including the client's direct quote, ensuring accurate and objective recording of the refusal, and noting that the healthcare provider was informed. It provides a clear, detailed account suitable for medical and legal purposes.
D. Healthcare provider notified that client is uncooperative and irritable, glucose level not assessed: Describing the client as uncooperative and irritable is subjective and could be considered judgmental. Proper documentation should remain objective, focusing on the client’s stated concerns rather than labeling their behavior.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. High school: Beginning screening at the high school level is too late for early intervention. By adolescence, many obesity-related habits and risk factors are already established, making prevention efforts less effective compared to earlier childhood interventions.
B. Elementary school: Screening during elementary school years is best because it allows early identification of unhealthy weight patterns. Early detection helps in promoting healthy lifestyle habits before adolescence, improving long-term outcomes and reducing the risk of chronic diseases.
C. Onset of puberty: While puberty brings significant physical changes, waiting until this stage may miss earlier opportunities for preventive education and intervention. Early habits formed in childhood often persist into adolescence and adulthood.
D. Kindergarten: Although health education can start early, formal obesity screening at kindergarten may be premature since normal variations in growth patterns are common at that age. Targeting elementary-aged children provides a better balance between early intervention and developmental appropriateness.
Correct Answer is A
Explanation
A. Notify the unit charge nurse of the client's reported symptoms immediately: Tingling and numbness can be signs of hyperkalemia, a serious and potentially life-threatening complication from potassium supplementation. Immediate reporting is necessary for prompt evaluation and intervention to prevent cardiac or neuromuscular complications.
B. Reassure the client that the supplement will soon relieve those symptoms: Symptoms like tingling and numbness are not expected side effects of potassium therapy. Reassurance without investigation could delay necessary medical treatment and worsen the client’s condition.
C. Explain that a calcium supplement may be necessary: Calcium supplementation is not the standard response to symptoms of potassium imbalance. Without a clear diagnosis, recommending additional supplements could complicate the clinical situation further.
D. Encourage the client to decrease the intake of dietary sodium: Although reducing sodium is generally beneficial for health, it does not address the acute issue of possible potassium imbalance causing neuromuscular symptoms. Immediate clinical evaluation takes priority.
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