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.

Answer and Explanation

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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Correct Answer is B

No explanation

A. "I'll use focused breathing to control my pain." B. "I'll learn to notice the sensation of muscle tension." C. "I'll think about my grandfather's farm to reduce pain." D. "I'll listen to my favorite music to take my mind off the pain."

Correct Answer is C

Explanation

Choice A Reason:

"I'll use focused breathing to control my pain." Is incorrect. Focused breathing is a relaxation technique that can complement guided imagery, but it's not specifically imagery-based. It's more aligned with techniques like mindfulness or deep breathing exercises.

Choice B Reason:

"I'll learn to notice the sensation of muscle tension." Is incorrect. Noticing muscle tension is a part of progressive muscle relaxation, a different technique aimed at reducing physical tension, which is different from guided imagery.

Choice C Reason:

"I'll think about my grandfather's farm to reduce pain." Is correct. Guided imagery involves focusing on specific mental images or scenarios to promote relaxation, reduce stress, and manage pain. Imagining a peaceful or pleasant place, like the client's grandfather's farm, can serve as a distraction and help reduce pain perception.

Choice D Reason:

"I'll listen to my favorite music to take my mind off the pain." Is incorrect. Listening to music can be a distraction technique, but it's not specifically guided imagery. While it might help in managing pain by diverting attention, it's not rooted in imagery-focused mental visualization.

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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?

Nursing Test Bank

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