A client tells a nurse, "I do not think I can have the recommended heart surgery because transfusions are against my religion." What is the best response of the nurse in this situation?
Prepare the client for a visit from the client's spiritual advisor.
Obtain all the information needed for the client to make an informed decision.
Tell the client that the surgery is necessary to keep them alive and is the only choice.
Have the client sign a form stating refusal of the treatment.
The Correct Answer is B
A. While involving a spiritual advisor may be helpful, the nurse’s priority is to ensure the client is fully informed before decisions are made.
B. Providing all relevant information allows the client to weigh risks and options and make an informed decision respecting their beliefs.
C. Forcing information or pressuring the client disregards their autonomy and beliefs.
D. Having the client sign refusal without thorough discussion does not support informed consent or shared decision-making.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While loneliness can contribute to distress, the specific behaviors observed (excessive religious reading, crying, and poor sleep) suggest something deeper than just social isolation.
B. These behaviors are signs of spiritual distress, which may occur when a person is facing a serious illness or surgery and is struggling with questions of meaning, faith, or fear. Spiritual distress can manifest emotionally and behaviorally, as seen here.
C. While some anxiety is expected before major surgery, persistent emotional signs like excessive crying and poor sleep, along with intense religious focus, indicate more than normal preoperative nerves.
D. Labeling the client as “naturally emotional” is an assumption and dismisses the need for assessment and appropriate support.
Correct Answer is C
Explanation
A. While instructors may have supervisory responsibility, the primary responsibility lies with the individual providing care.
B. The primary nurse may have a role in supervision, but the student is accountable for following clearly defined dietary orders.
C. The same standards of care that apply to a registered nurse apply to the student when performing tasks within their scope of practice and training. This means students are expected to know and follow proper procedures and orders, including dietary restrictions.
D. Insurance may cover legal costs, but it does not negate liability. The student is still accountable for the outcome of their actions.
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