A client with schizophrenia is reluctant to take his prescribed oral medication. The most therapeutic response by the nurse to this refusal is:

"I can see that you're uncomfortable now, so we can wait until tomorrow."

"If you refuse these pills, you'll have to get an injection

"What is it about the medicine that you don't like?"

"You know you have to take this medicine for your own good."

Answer and Explanation

The Correct Answer is C

A. "I can see that you're uncomfortable now, so we can wait until tomorrow." Delaying the medication could worsen the client's condition and does not address the underlying reason for the refusal.

B. "If you refuse these pills, you'll have to get an injection." This response is coercive and could damage trust between the client and the nurse. It does not explore the client's concerns.

C. "What is it about the medicine that you don't like?" This response is therapeutic as it opens a dialogue with the client to understand their concerns, which can help in addressing the reluctance and promoting adherence to the medication.

D. "You know you have to take this medicine for your own good." This response is paternalistic and dismisses the client's autonomy and concerns, which may lead to further resistance.

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Correct Answer is A

Explanation

A. Risk for aspiration: The gag reflex is crucial for preventing aspiration. An absent gag reflex significantly increases the risk of food or fluids entering the airway, leading to aspiration pneumonia or choking.

B. Risk for falls: While risk for falls is a concern in stroke patients, the immediate risk related to the absence of the gag reflex is more directly associated with aspiration.

C. Risk for impaired skin integrity: Impaired skin integrity is important but is a secondary concern compared to the risk of aspiration due to the absence of the gag reflex.

D. Decreased intracranial adaptive capacity: This diagnosis relates to the brain's ability to adapt to changes. While important, it is less immediately relevant compared to the risk of aspiration from the loss of the gag reflex.

A. Sit with the client for a few minutes. B. Administer an analgesic. C. Inform the nurse manager. D. Call the health care provider immediately.

Correct Answer is D

Explanation

A. Sit with the client for a few minutes. While providing comfort is important, it does not address the immediate need to evaluate and manage a potentially serious condition.

B. Administer an analgesic. Administering analgesics without assessing the cause of the headache might mask symptoms of a serious issue. This is not the priority action.

C. Inform the nurse manager. Informing the nurse manager is important but does not directly address the client’s immediate needs or potential emergency.

D. Call the health care provider immediately. Reporting severe headache in a client with a cerebral aneurysm is critical as it could indicate worsening of the condition, such as aneurysm rupture or increased intracranial pressure. Immediate action is required to prevent further complications.

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A client with schizophrenia is reluctant to take his prescribed oral medication. The most therapeutic response by the nurse to this refusal is:

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Naxlex Comprehensive Predictor Exams

A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. This deficit is related to cranial nerve (CN) X, the vagus nerve. What will the nurse consider a priority nursing diagnosis?

Correct Answer is A

Explanation

A client diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse?

Correct Answer is D

Explanation

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