Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
72. A client is combative and demanding and refuses to swallow any medication following a brain attack (CVA). The correct nursing action is to:
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
72. A client is combative and demanding and refuses to swallow any medication following a brain attack (CVA). The correct nursing action is to:
. Continue to attempt to follow the physician's orders and give the medication anyway.
. Determine what the client's personality was before the CVA.
. Apply restraints and request a change in the route of medication.
. Wait for the client to become more cooperative.
Test-Taking Tip
Choose an option that recognizes the effect of the brain attack on behavior. Select the option for further assessment ("determine personality before . . .") in an attempt to understand the behaviors.
Content Area: Adult Health, Cardiovascular; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Psychosocial Integrity/Behavioral Interventions
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
.
Answer 1 is incorrect because the client cannot be forced to take an oral medication. Answer 2 is correct because the behavior may be a pattern. Family may have suggestions that will help. Answer 3 is incorrect because restraints should be a last resort if at all possible. The route may need to be changed. Answer 4 is incorrect because the behavior may be the result of the brain injury and may not change.