NCLEX-RN

Category - Care Management

Nina the New Nurse is caring for a client recovering from surgical repair of a left hip fracture. The client also has a history of schizophrenia. After assessing the surgical site, Nina the New Nurse administers a prescribed routine medication, Risperdal 6mg, PO. The client refuses the medication, saying, “I’m not going to take this anymore. I don’t know what it is, what it does, or why I have to take it. Maybe it’s the reason I’m so tired all the time.” Which of the following is Nina the New Nurse’s best response?
  1. Tell the client, “OK, you certainly have the right to refuse your medication,” then dissolve the medication into the client’s favorite juice and offer the juice to the client.
  2. Tell the client, “This is a multivitamin. Some people experience a little upset stomach, but multivitamins don’t usually make a person drowsy.” Nina the New Nurse understands a schizophrenic client may not cooperate with a therapeutic medication regime, and should advise the client of the purposes and side effects of a multivitamin.
  3. Ask the client, “Do you feel like everyone is out to get you? Are you experiencing hallucinations?”, and follow up with a referral for a psychiatric evaluation and treatment.
  4. Say to the client, “Would you like to discuss your concerns? I might be able to answer some of your questions. Maybe I can give you more information before you make a decision.”
Explanation
Answer: D - All clients have the right to understand why their physician has prescribed a medication, treatment, or diagnostic procedure, as well as the therapeutic goal and possible side effects. All clients also have the right to refuse medical treatment. It is a nurse’s duty to provide clear information and explanation of suggested treatments, prescribed medications, or diagnostic procedures so that the client can determine what is best for him/herself. In addition, all clients have the right to be treated with dignity and respect; answers A, B and C violate these rights.
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