A client says to the nurse “I will not take the prescribed medication today.” What should be the initial action by the nurse?
Listen to the reason for refusal.
Report refusal to the charge nurse.
Explain the purpose of the medication.
Encourage the client to take the medication.
The Correct Answer is A
This is the most therapeutic response because it shows respect for the client’s autonomy and allows the nurse to explore the client’s concerns and feelings about the medication.
It also helps to establish trust and rapport with the client. Choice B. Report refusal to the charge nurse.
This is wrong because it does not address the client’s immediate needs and may make the client feel ignored or dismissed.
Choice C. Explain the purpose of the medication.
This is wrong because it may sound like lecturing or persuading the client, which can increase resistance and hostility.
Choice D. Encourage the client to take the medication.
This is wrong because it does not acknowledge the client’s right to refuse treatment and may imply that the nurse knows better than the client what is best for them.
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Correct Answer is D
Explanation
This is because helping the client to recognize and avoid situations that cause anxiety can reduce the frequency and severity of acute anxiety episodes. According to , a nurse should encourage the client to verbalize feelings and provide a calm and supportive environment.
Choice A is wrong because isolating the client when there are observable physiologic symptoms of anxiety can increase the client’s sense of fear and loneliness.
The nurse should stay with the client and offer reassurance and comfort.
Choice B is wrong because ignoring the client’s behavior as obvious attempts to gain attention can make the client feel rejected and misunderstood.
The nurse should acknowledge the client’s feelings and provide empathy and support.
Choice C is wrong because reducing all stress whenever the client seems anxious can prevent the client from learning coping skills and developing resilience.
The nurse should help the client to identify healthy ways of managing stress and anxiety.
Correct Answer is B
Explanation
Are you taking the medication as prescribed? This is because warfarin is a blood-thinning medication that affects the prothrombin time (PT) and the international normalized ratio (INR).
The PT measures how long it takes for blood to clot, and the INR is a calculation based on the PT that standardizes the results across different laboratories. A normal INR range is 0.8 to 1.1 for people who are not taking warfarin. People who take warfarin usually have a target INR range of 2 to 3, depending on their condition.
An INR of 0.8 means that the blood clots faster than normal, which increases the risk of blood clots and strokes.
This could indicate that the client is not taking enough warfarin or is taking other medications or foods that interfere with warfarin’s effect.
Choice A is wrong because bleeding gums are a sign of excessive bleeding, which could happen if the INR is too high, not too low.
Choice C is wrong because blood in stools is also a sign of excessive bleeding, which could happen if the INR is too high, not too low.
Choice D is wrong because unusual bruising is another sign of excessive bleeding, which could happen if the INR is too high, not too low.
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