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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Decreasing the volume on the hearing aid is correct. Whistling or feedback in a hearing aid can often occur due to excessive volume. Lowering the volume can help eliminate or reduce the whistling sound without disrupting the functioning of the hearing aid.
Choice B Reason:
Cleaning the hearing aid with isopropyl alcohol is incorrect. While cleaning the hearing aid is essential for maintenance, using isopropyl alcohol might not resolve the issue of whistling. It's more for general hygiene and cleanliness of the device.
Choice C Reason:
Turning the hearing aid off for 5 minutes is incorrect. Turning off the hearing aid might not address the specific issue of whistling. Additionally, it could inconvenience the client's ability to hear during that time.
Choice D Reason:
Soaking the hearing aid in warm water is incorrect. Soaking a hearing aid in water is not a recommended method, as it could damage the device and its electronic components. Water exposure might also worsen the issue instead of resolving it.
Correct Answer is C
Explanation
Choice A Reason:
Including the family member in providing care for the client is incorrect. While involving the family in care might be helpful for some, not all family members might feel comfortable or capable of participating in direct care during such an emotional and difficult time. Asking their preferences and respecting their boundaries is crucial.
Choice B Reason:
Describing a personal experience with the death of a family member is incorrect. Sharing personal experiences could potentially be inappropriate or overwhelming for the family member. It might inadvertently shift the focus away from the client's needs and emotions.
Choice C Reason:
Asking if they have had prior experience with the death of a family member is correct. This approach allows the nurse to understand the family member's prior experiences with death, providing insights into their understanding, fears, and expectations. It also helps the nurse tailor their support accordingly, acknowledging their emotions and offering assistance that aligns with their comfort level.
Choice D Reason:
Suggesting that the family member contact a grief counselor is incorrect. While grief counseling might be beneficial, suggesting it immediately might not address the family member's immediate need or desire to help in the moment. It's essential to acknowledge their offer to help and offer immediate support or guidance that aligns with their comfort level.
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