A nurse in an inpatient mental health facility is caring for a client who has major depressive disorder and refuses to take her medication. Which of the following actions should the nurse take first?
Explain to the client the consequences of refusal.
Identify the reason for the client's refusal.
Document the client's refusal in the medical record.
Inform the provider of the client's refusal.
The Correct Answer is B
A. While explaining the consequences of refusal is important, it may not address the underlying reason for the refusal and should come after identifying the reason.
B. Identifying the reason for the client's refusal is the first step in addressing the issue and may help determine the appropriate intervention.
C. Documenting the client's refusal is important but should not be the first action taken without understanding the reason for the refusal.
D. Informing the provider of the client's refusal may be necessary, but it should come after identifying the reason for the refusal and attempting to address it.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.
A. Ventrogluteal - The ventrogluteal site is preferred for intramuscular injections in adults due to its proximity to large, deep muscles and minimal risk of injury to major nerves and blood vessels.
B. Dorsogluteal - The dorsogluteal site is not recommended for intramuscular injections due to the risk of injury to the sciatic nerve and superior gluteal artery.
C. Vastus lateralis - The vastus lateralis is a safe site for intramuscular injections, particularly in infants and young children.
D. Rectus femoris - The rectus femoris muscle is not typically used for intramuscular injections due to its superficial location and proximity to major blood vessels.
Correct Answer is A
Explanation
A.
A. Clear fluid drainage from the nares, especially if it is continuous or persistent, may indicate a cerebrospinal fluid (CSF) leak, which can occur with a skull fracture.
B. Pain around the eyes is more commonly associated with a nasal fracture or orbital fracture, rather than a skull fracture.
C. Dried blood in the mouth may indicate nasal bleeding but does not necessarily indicate a skull fracture.
D. Mandibular asymmetry may indicate a jaw fracture or injury but is not typically associated with a skull fracture.
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