A nurse is caring for a client who refuses their morning dose of antihypertensive medication. The client tells the nurse, "I'm not going to take this medication because it makes me sick and dizzy." Which of the following actions should the nurse take first?
Document the refusal in the client's medical record.
Return the medication to the medication cabinet.
Inform the client of the potential consequences of their refusal.
Notify the provider of the client's refusal.
The Correct Answer is C
Choice A Reason:
While documenting the refusal is important for accurate record-keeping and to ensure communication among the healthcare team, addressing the client's immediate concerns and attempting to resolve the issue of medication refusal should take precedence before documenting.
Choice B Reason:
Returning the medication is a procedural step but is not the immediate action needed when a client refuses medication due to adverse effects. First, it's important to address the client's concerns and discuss the potential consequences of refusal.
When a client refuses medication due to experiencing adverse effects, the initial action for the nurse to take is:
Choice C Reason:
Inform the client of the potential consequences of their refusal is correct. It's essential to engage in a conversation with the client to understand their concerns and educate them about the potential consequences of not taking their antihypertensive medication. The nurse should discuss the risks associated with untreated high blood pressure to ensure the client is informed about the importance of the prescribed medication.
Choice D Reason:
Notifying the provider is important, but it is generally done after the nurse has attempted to address the client’s concerns and informed them of the consequences. The provider should be informed if the refusal persists or if the nurse believes the situation requires further medical intervention.
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Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Turn on loud music in client care areas is incorrect. This action might increase stress rather than reduce it. Loud noises or music can be distressing for clients, especially in a healthcare setting where rest and recovery are crucial. It's generally better to maintain a calm and quiet environment.
Choice B Reason:
Assign different nurses to provide care for clients each day is incorrect. Continuity of care is often beneficial for clients, as it fosters trust and familiarity. Having different nurses daily might disrupt this continuity and potentially increase stress for clients who prefer consistent caregivers.
Choice C Reason:
While offering some choices can empower clients and reduce stress, too many choices might overwhelm them, particularly in an acute care setting. The key is to provide a balance of autonomy while not overwhelming the client.
Choice D Reason:
Limiting the number of visitors can help create a quieter, more controlled environment, reducing overstimulation and stress for clients. This can be particularly important in an acute care setting where rest and a calm environment are crucial for recovery.
Correct Answer is C
Explanation
Choice A Reason:
"I can't change my mind about the care I will receive once I sign my living will." Is incorrect.
This statement suggests a misconception that signing a living will locks in a permanent decision, whereas advance directives can usually be updated or modified as long as the individual is competent to do so.
Choice B Reason:
"If I want life support, I'll need to sign a separate consent form first." Is incorrect. While the concept of a consent form for specific treatments is relevant, it might not fully reflect the broader scope of advance directives, which encompass a range of healthcare preferences beyond just life support.
Choice C Reason:
"I'm glad to have the opportunity to choose what kind of care I receive while I still can." Is correct. This statement reflects the understanding that advance directives offer the opportunity to make decisions about the type of care the client wishes to receive or avoid, empowering them to express their preferences while they are still able to do so.
Choice D Reason:
"Once I fill out my living will, there will be a 1-month delay before it is legally binding." Is incorrect. There isn't typically a standardized waiting period before an advance directive becomes legally binding. The legal validity and activation of advance directives vary by region, but they usually become effective immediately upon completion unless stated otherwise or specific requirements apply.
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