A nurse on a medical-surgical unit is preparing to administer an influenza vaccine to a client.
The client tells the nurse, "I no longer want to receive this vaccine."
Which of the following responses should the nurse make?
"If I were you, I would get the vaccine to keep my family safe.”
"Influenza can be very serious to anyone who does not receive the vaccine.”
"The influenza vaccine is strongly encouraged, but I understand you would like to decline right now.”
"The influenza vaccine is mandatory for all clients before discharge, so you will need to sign an against medical advice form.”
The Correct Answer is C
The correct answer is Choice C.
Choice A rationale:
- This response is not appropriate because it is judgmental and may make the client feel defensive.
- It is important for the nurse to respect the client's right to make their own decisions about their health care.
- Telling the client what they should do can undermine their autonomy and potentially damage the nurse-client relationship.
- It's crucial for the nurse to remain objective and avoid imposing their personal opinions or beliefs onto the client.
Choice B rationale:
- This response is also not appropriate because it is using scare tactics to try to persuade the client to get the vaccine.
- This approach can be counterproductive and may further alienate the client.
- It's important to provide accurate information about the risks and benefits of the vaccine in a neutral and non-threatening manner.
Choice C rationale:
- This is the most appropriate response because it acknowledges the client's right to refuse the vaccine while still encouraging them to get it.
- It also demonstrates respect for the client's autonomy and validates their feelings.
- This approach is more likely to foster a positive nurse-client relationship and keep the door open for future discussions about vaccination.
Choice D rationale:
- This response is not accurate because the influenza vaccine is not mandatory for all clients before discharge.
- It is important for the nurse to provide accurate information to the client.
- Threatening the client with an against medical advice form is not appropriate and may be considered a form of coercion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Administer the medication through a straw.
This is because ferrous sulfate elixir can stain the teeth, so using a straw can help prevent this from happening.
Choice A is wrong because milk can interfere with the absorption of iron.
Choice B is wrong because caffeine can also interfere with iron absorption.
Choice D is wrong because antacids can reduce the absorption of iron and should be avoided within 2 hours of taking ferrous sulfate.
Correct Answer is B
Explanation
Anaphylaxis is a severe, potentially life-threatening allergic reaction that can occur within seconds or minutes of exposure to an allergen, such as penicillin.
One of the symptoms of anaphylaxis is wheezing, which is caused by the constriction of the airways and a swollen tongue or throat.
Choice A is wrong because hypertonia (increased muscle tone) is not a known symptom of anaphylaxis.
Choice C is wrong because urinary retention (inability to completely empty the bladder) is not a known symptom of anaphylaxis.
Choice D is wrong because increased blood pressure is not a known symptom of anaphylaxis; in fact, anaphylaxis can cause a sudden drop in blood pressure.
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