A nurse is caring for a client who has a new diagnosis of diabetes mellitus and is refusing to learn how to self-administer insulin. Which of the following responses should the nurse make?
“I’d like to hear your thoughts about giving yourself this medication.”
"You will suffer serious health issues if you don't take your medication."
"Why don't you want to learn how to give yourself your medication?"
“Have you considered how your decision to refuse medication will affect your family?"
The Correct Answer is A
A. “I’d like to hear your thoughts about giving yourself this medication.”: This response uses open-ended, therapeutic communication that invites the client to express concerns, fears, or misconceptions. It demonstrates respect for autonomy and helps build trust while allowing the nurse to assess readiness to learn. Understanding the client’s perspective is essential before providing education or problem-solving.
B. “You will suffer serious health issues if you don't take your medication.”: This response uses fear and threats, which can increase anxiety and resistance rather than promote cooperation. It does not encourage dialogue or address the client’s underlying concerns.
C. “Why don't you want to learn how to give yourself your medication?”: Questions beginning with “why” can feel accusatory or judgmental, causing the client to become defensive. Although the nurse needs to understand the client’s reluctance, this phrasing may inhibit open communication. A more neutral approach is preferred.
D. “Have you considered how your decision to refuse medication will affect your family?”: This response applies guilt and shifts the focus away from the client’s feelings and autonomy. It does not promote therapeutic communication or support informed decision-making. Using guilt can undermine trust and collaboration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
A. Respiratory rate: A respiratory rate of 30 breaths per minute indicates significant respiratory distress. Labored breathing combined with crackles and wheezes suggests impaired gas exchange and possible lower respiratory infection requiring urgent intervention.
B. Oxygen saturation level: An oxygen saturation of 89% on room air reflects hypoxemia. Reduced oxygen levels place the client at risk for tissue hypoxia and worsening respiratory failure, making prompt follow-up and oxygen therapy necessary.
C. Chronic health condition: A history of smoking, Parkinson’s disease, and anxiety increases overall health risk but does not explain the acute deterioration. Chronic conditions provide context but are not the immediate priority compared with current unstable findings.
D. Tremors: Hand tremors are consistent with Parkinson’s disease and may also be worsened by anxiety or illness. Tremors alone do not pose an immediate life-threatening risk in this situation.
E. Current level of consciousness: Orientation only to self and failure to follow commands suggest acute changes in mental status. Altered cognition in an older adult with fever and hypoxia may indicate delirium or worsening infection and requires immediate evaluation.
F. Heart rate: A heart rate of 104 beats per minute indicates mild tachycardia, likely related to fever or hypoxia. Although important to monitor, it is less immediately threatening than hypoxemia, tachypnea, and altered mental status.
Correct Answer is A
Explanation
A. Observe the client during and after meals: Monitoring the client for bingeing or purging behaviors is the priority intervention because it addresses immediate safety and physical health risks, such as electrolyte imbalances. Direct observation prevents harmful behaviors and allows timely intervention.
B. Refer the client to a support group for clients who have eating disorders: Referral is important for long-term psychosocial support, but it does not address immediate risk or safety concerns during meals.
C. Instruct the client about effective coping strategies: Teaching coping strategies is beneficial for long-term management, but ensuring safety during meals takes precedence in the nursing process.
D. Suggest that the client assist with meal planning: Involving the client in meal planning promotes autonomy and engagement in treatment, but it is not the first action when immediate monitoring is required to prevent harmful behaviors.
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