A nurse is caring for a client who has schizophrenia and is refusing to take a prescribed medication. Which of the following actions should the nurse take?
Remind the client that they have been refusing the medication for 5 days.
inform the client that their provider will contact them to discuss their refusal of the medication
Document the client's refusal in the medication administration record.
Notify the pharmacy about the client's refusal of the medication
The Correct Answer is C
A. Remind the client that they have been refusing the medication for 5 days: Pointing out the duration of refusal may come across as confrontational and does not respect the client's right to refuse treatment. It can also damage the therapeutic relationship without addressing the underlying concerns about the medication.
B. Inform the client that their provider will contact them to discuss their refusal of the medication: While involving the provider may eventually be necessary, the immediate nursing action should be to document the refusal accurately. The nurse can then inform the provider if needed based on facility policy.
C. Document the client's refusal in the medication administration record: Clients have the legal right to refuse medication, and it is the nurse’s responsibility to document the refusal clearly and objectively. Accurate documentation ensures legal protection for the client and the healthcare team and maintains the integrity of the medical record.
D. Notify the pharmacy about the client's refusal of the medication: Notifying the pharmacy about a single medication refusal is unnecessary unless there are repeated refusals requiring a change in the medication order. The pharmacy’s role is not to manage client compliance but to dispense prescribed medications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "I should limit my intake of leafy green vegetables.": Limiting leafy green vegetables is associated with warfarin therapy because of their vitamin K content. It is not relevant to metoprolol, which primarily affects the cardiovascular system and does not interact significantly with dietary vitamin K.
B. "I may experience loss of taste.": Loss of taste is not a common side effect of metoprolol. Metoprolol is more associated with cardiovascular side effects such as bradycardia, hypotension, and dizziness rather than alterations in taste perception.
C. "I need to be careful when standing up from bed.": This is correct because metoprolol can cause orthostatic hypotension, leading to dizziness or lightheadedness upon standing. Clients are advised to rise slowly from a lying or seated position to reduce the risk of falls and fainting.
D. "I should expect some weight loss.": Metoprolol is more commonly associated with weight gain or no significant weight change rather than weight loss. Clients taking beta-blockers sometimes experience fluid retention or a slowed metabolism, leading to modest weight gain.
Correct Answer is D
Explanation
A. Difficulty swallowing: Difficulty swallowing, or dysphagia, is not typically a direct indicator of unrelieved pain. It could suggest neurological or throat-related issues rather than being a primary symptom associated with inadequate pain control.
B. Constipation: Constipation is a common postoperative complication, often related to anesthesia, immobility, or opioid use. While it is important to address, it does not directly reflect the client's current pain level or effectiveness of pain management.
C. Urinary retention: Urinary retention can occur due to anesthesia effects, pelvic surgery, or opioid administration. Although it is a significant postoperative concern, it is not a reliable or direct indicator of unrelieved pain.
D. Restlessness: Restlessness is a common sign of unrelieved pain, particularly in postoperative clients. When clients are uncomfortable or in significant pain, they may appear restless, anxious, or unable to remain still, signaling the need for further pain assessment and intervention.
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