When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room.
Which action should the nurse take?
Refer client to the social worker for support therapy.
Encourage client to implement relaxation techniques.
Leave the client's room and return later in the day.
Explain that insulin is a life-saving drug for the client.
Explain that insulin is a life-saving drug for the client.
The Correct Answer is C
Choice A rationale:
Referring the client to a social worker for support therapy may be premature at this stage. The client's initial reaction may be due to fear or anxiety about the diagnosis and self-administration of insulin. Pushing the client into therapy without assessing their readiness may not be appropriate.
Choice B rationale:
Encouraging the client to implement relaxation techniques assumes that the client is open to learning and just needs help with anxiety management. However, the client's refusal to have the nurse in the room suggests that they are not currently receptive to teaching. It's important to address the client's emotional state first.
Choice C rationale:
Leaving the client's room and returning later in the day is the most appropriate initial action. The client's loud refusal indicates a need for privacy and emotional space. By respecting the client's wishes and revisiting the teaching later, the nurse can establish trust and build a better rapport.
Choice D rationale:
Explaining that insulin is a life-saving drug is informative but may not be effective in this situation, as the client has already requested the nurse to leave the room. Providing information about the importance of insulin should come after establishing a therapeutic nurse-client relationship.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
“Reflection is thinking about what I did and how I can improve.” Rationale: Reflection involves self-assessment and critical thinking about past actions to identify areas for improvement. This statement correctly defines reflection and does not indicate a need for further teaching.
Choice B rationale:
“Analysis is breaking down a complex situation into smaller parts.” Rationale: Analysis is the process of examining complex situations by breaking them down into smaller, manageable components for a more in-depth understanding. This statement accurately describes analysis and does not indicate a need for further teaching.
Choice C rationale:
“Inference is making assumptions based on my experience.” Rationale: Inference involves drawing conclusions or making predictions based on available evidence rather than personal experience. This statement incorrectly defines inference, indicating a need for further teaching.
Choice D rationale:
“Evaluation is checking the reliability and validity of information.” Rationale: Evaluation refers to the process of assessing the credibility, accuracy, and relevance of information or data. This statement accurately defines evaluation and does not indicate a need for further teaching.
Correct Answer is C
Explanation
Medication administration is a process that involves prescribing, dispensing, and giving medications to patients. It is a critical and complex task that requires accuracy, safety, and adherence to the rights of medication administration, such as the right patient, right drug, right dose, right route, right time, right documentation, and right response.
When a male client tells the practical nurse (PN) that the pill he has been taking at home is a different color and size than the one the PN is trying to give him now, this may indicate a potential medication error or discrepancy. A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm. A medication discrepancy is any difference between the current and previous medication regimens of a patient.
The PN should respond to the client's concern by telling him that the PN will verify that the dispensed medication is the valid prescription. This means that the PN will check the medication label, the medication order, and the medication administration record (MAR) to confirm that the medication given to the client matches the one prescribed by the healthcare provider. The PN will also compare the dispensed medication with a drug reference guide or a picture of the medication to ensure that it is the correct drug and dosage form. The PN will also report any suspected errors or discrepancies to the healthcare provider or the pharmacy for clarification or correction.
Options A, B, and D are incorrect answers, as they do not reflect the appropriate or responsible actions for the PN to take when faced with a possible medication error or discrepancy.
Option A is incorrect because explaining that the healthcare provider probably prescribed a different medication while he is hospitalized is not true or helpful, as it does not verify or resolve the issue.
Option B is incorrect because telling the client that he is probably confused since being hospitalized tends to disorient clients is rude and dismissive, as it does not acknowledge or address the client's concern.
Option D is incorrect because explaining that the pharmacy often substitutes generic equivalents for more expensive brands is not accurate or relevant, as it does not verify or resolve the issue.
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