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 A
Explanation
A. Increase the daily oral fluid intake: Increasing fluid intake is one of the best non-pharmacological strategies to prevent constipation, especially in older adults. Adequate hydration helps soften stool, promotes regular bowel movements, and supports overall digestive health during travel and routine changes.
B. Decrease the fat content in your diet: Reducing dietary fat is more related to managing cardiovascular health rather than preventing constipation. Fats themselves do not contribute significantly to constipation, and this advice would not directly address the client's specific concern.
C. Use an over-the-counter (OTC) stool softener: While stool softeners can be useful, recommending their routine use without first trying dietary and lifestyle modifications is not the best initial approach. Relying on medications can sometimes lead to dependency or mask underlying issues.
D. Eat a high-protein diet: High-protein diets without sufficient fiber and fluids can actually worsen constipation. Protein is important for overall health, but preventing constipation primarily requires fiber intake and adequate hydration rather than increased protein alone.
Correct Answer is B
Explanation
A. When the pain interferes with activities of daily living: Waiting until pain affects daily functioning may cause unnecessary suffering and make pain harder to control. Postoperative pain management aims to address discomfort early before it escalates to a level that impairs normal activity.
B. As soon as the client begins to feel pain: Asking for pain medication at the onset of pain allows for more effective management. Treating pain early prevents the development of severe pain, enhances comfort, and often requires lower doses of medication compared to managing severe pain later.
C. When the client can no longer move comfortably: Delaying pain management until mobility is significantly impaired increases the risk of complications such as immobility, poor wound healing, and longer hospital stays. Early intervention is crucial for better outcomes.
D. Once the pain gets to a moderate level: Allowing pain to reach a moderate intensity before requesting medication can make it more difficult to control. It is better to preemptively manage pain to prevent escalation, leading to faster recovery and improved participation in rehabilitation activities.
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