The nurse prepares to administer a medication to a client, who refuses to take it. What is the priority action of the nurse?

Document the refusal and its management.

Notify the healthcare provider of the patient's refusal.

Speak with the client to determine the reason for the refusal.

Identify to the client the irrational reason for refusing part of the therapy

Answer and Explanation

The Correct Answer is C

A. Document the refusal and its management: Documentation is a legal requirement that follows the intervention but does not constitute the immediate priority. The nurse must first engage in clinical inquiry to address the client's concerns or misconceptions. Recording the event occurs only after all attempts at education and assessment are exhausted.

B. Notify the healthcare provider of the patient's refusal: While the prescriber must eventually be informed of deviations from the treatment plan, this is not the first step. The nurse should first gather pertinent data regarding the refusal to provide a comprehensive report. Immediate notification without assessment is premature and inefficient.

C. Speak with the client to determine the reason for the refusal: The primary responsibility is to respect patient autonomy while ensuring informed consent or refusal. Identifying specific barriers, such as fear of side effects or lack of understanding, allows the nurse to provide targeted education. This assessment phase is essential for therapeutic communication.

D. Identify to the client the irrational reason for refusing part of the therapy: Labeling a patient's concerns as "irrational" is non-therapeutic and damages the nurse-client relationship. It violates the principle of respect and may increase the client's defensiveness. Education should be objective and supportive rather than judgmental or confrontational.

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Correct Answer is A

Explanation

A. Muscle atrophy: Prolonged immobilization leads to disuse atrophy of the skeletal muscles as they are not subjected to normal tension and workload. After 6 weeks in a cast, a noticeable decrease in the circumference of the calf and thigh muscles is a standard clinical finding.

B. Slow capillary refill: Capillary refill is a measure of peripheral perfusion and should return to normal once the restrictive cast is removed. Unless there is underlying vascular disease, the immobilization itself does not permanently impair the microcirculation of the toes or skin.

C. Inversion contracture: While joint stiffness is common after casting, a specific inversion contracture is not a standard expected finding of simple immobilization. Range of motion is typically restricted in all planes initially, but permanent pathological contractures are avoided through proper positioning and subsequent physical therapy.

D. Diminished pedal pulse: The presence of a cast does not typically cause a permanent decrease in arterial pulse strength once removed. Pulses should be palpable and strong unless a vascular complication occurred during the casting period. Immobilization affects muscle mass rather than arterial lumen integrity.

A. The client is dehydrated. B. The client has impaired perfusion. C. The client has diminished demand for oxygen. D. The client has developed hypostatic pneumonia.

Correct Answer is D

Explanation

A. The client is dehydrated: Dehydration typically presents with systemic signs such as poor skin turgor, dry mucous membranes, and tachycardia rather than localized adventitious breath sounds. While it can thicken secretions, it does not directly cause crackles and rhonchi in a specific lung lobe.

B. The client has impaired perfusion: Perfusion issues generally manifest as cyanosis, delayed capillary refill, or cool extremities rather than specific pulmonary congestion. While heart failure can lead to pulmonary edema, the localized nature of the sounds suggests a primary ventilatory or infectious complication.

C. The client has diminished demand for oxygen: A respiratory rate of 28 breaths per minute indicates tachypnea, which is a physiological response to an increased, not decreased, demand for oxygen. The body is attempting to compensate for impaired gas exchange within the congested alveolar spaces.

D. The client has developed hypostatic pneumonia: Prolonged immobility in a comatose state leads to the pooling of secretions in the dependent portions of the lungs. This stasis provides a medium for bacterial growth, resulting in infection, diminished aeration, and characteristic crackles or rhonchi.

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The nurse prepares to administer a medication to a client, who refuses to take it. What is the priority action of the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client following removal of a cast of the left lower leg. The cast had been in place for six weeks. Which assessment finding(s) of the left leg does the nurse anticipate identifying?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

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The nurse prepares to administer a medication to a client, who refuses to take it. What is the priority action of the nurse?

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