A nurse is assessing a client’s understanding of their medication regimen. The client nods in agreement but does not respond verbally. What is the nurse’s best action?
Assume the client understands and proceed with the regimen.
Repeat the instructions using different words.
Document that the client has full understanding of the regimen.
Ask the client to verbally respond to the Questions.
The Correct Answer is D
Choice A rationale
Assuming the client understands and proceeding with the regimen is incorrect. It does not verify the client’s understanding and could lead to non-compliance or errors in medication administration.
Choice B rationale
Repeating the instructions using different words may help, but it does not ensure that the client has understood the information. It is important to verify understanding through the client’s response.
Choice C rationale
Documenting that the client has full understanding of the regimen without verification is incorrect. It assumes understanding without confirmation, which could lead to potential errors.
Choice D rationale
Asking the client to verbally respond to the questions is the best action. It ensures that the client has understood the information and allows the nurse to clarify any misunderstandings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Tertiary prevention involves managing and rehabilitating patients with established diseases to prevent complications and improve quality of life. Referring a client to a specialist for further evaluation does not fit this category.
Choice B rationale
Primary prevention aims to prevent the onset of disease by reducing risk factors and promoting health. Referring a client to a specialist for further evaluation is not primary prevention.
Choice C rationale
Secondary prevention involves early detection and treatment of disease to prevent progression. Referring a client to a specialist for further evaluation fits this category as it aims to identify and address health issues early.
Choice D rationale
“Disease process” is not a recognized level of prevention. The correct levels are primary, secondary, and tertiary.
Correct Answer is B
Explanation
Choice A rationale
A Do Not Resuscitate (DNR) order is a type of advance directive that specifies that CPR should not be performed if the patient’s heart stops.
Choice B rationale
A trust fund is not a type of advance directive. It is a financial arrangement that does not relate to medical decisions.
Choice C rationale
A durable power of attorney for healthcare is a type of advance directive that allows an individual to appoint someone to make medical decisions on their behalf.
Choice D rationale
A living will is a type of advance directive that outlines an individual’s preferences for medical treatment in certain situations.
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