Question

a female client refuses to take an oral hypoglycemic agent because she believes that the drug is being administered as part of an elaborate plan by the mafia to harm her. which nursing intervention is most important to include in this clients plan of care?

reassure the client that no one will harm her while she is in the hospital.
ask the healthcare provider to give the client the medication.
explain that the diabetic medication is important to take.
reassess clients mental status for thought processes and content.

Explanation:

Analyze the client's presentation and behavior

The client is exhibiting a persecutory delusion (believing the Mafia is trying to harm her through her medication) and is refusing her oral hypoglycemic agent.

Evaluate the nursing process and priority actions

Before implementing interventions (such as attempting to reassure, explain, or change the route of medication), the nurse must first assess the client's current mental status, specifically focusing on thought processes and content, to understand the severity and nature of the delusion.

Assess the options

• Reassuring the client or explaining the medication's importance is ineffective when a client is actively delusional and may violate trust.
• Asking the provider to change the route does not address the underlying psychiatric issue.
• Reassessing the client's mental status is the essential first step in the nursing process.

Answer:

• Reassure the client that no one will harm her while she is in the hospital.
• Ask the healthcare provider to give the client the medication.
• Explain that the diabetic medication is important to take.
• Reassess client's mental status for thought processes and content. (Correct answer)