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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. Medications are limited to managing pain: While pain management is a key component of hospice care, medications are not limited only to pain management. Hospice care also addresses other symptoms like shortness of breath, nausea, and anxiety to improve comfort.
B. Care can be provided in the home: Hospice care can indeed be provided in the home, allowing the client to remain in a familiar environment while receiving palliative care. This is a central aspect of hospice services.
C. Care focuses on quality of life at the end of life: Hospice care prioritizes comfort and quality of life, providing emotional, spiritual, and physical support for both the client and family at the end of life.
D. Curative measures are optional: In hospice care, curative treatments are typically discontinued because the focus shifts to palliative care aimed at comfort and symptom relief rather than attempting to cure the illness.
E. Family is responsible for care decisions: While families are involved in decisions, hospice care involves collaboration with the healthcare team, and decisions are made based on the patient's wishes and comfort, not solely by the family.
Correct Answer is A
Explanation
A. Visitors should only wash hands with soap and water: Handwashing with soap and water is essential because alcohol-based sanitizers are ineffective against Clostridium difficile spores. Physical friction from washing removes spores and significantly reduces the risk of transmission.
B. Standard precautions apply to clients with active diarrhea: Clients with C. difficile require contact precautions, not just standard precautions, due to the high risk of environmental contamination and spore transmission through direct and indirect contact.
C. Clostridium difficile spores do not live long on surfaces outside of the host: C. difficile spores are very hardy and can survive on surfaces for long periods, sometimes weeks or months, making environmental cleaning and personal hygiene critical.
D. Only immunosuppressed family members should take precautions: All visitors and healthcare workers must use precautions, not just immunosuppressed individuals, because C. difficile is highly contagious and can infect healthy individuals through spore ingestion.
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