A nurse is assisting in the care of a client who has terminal cancer. Which of the following actions should the nurse take to promote the client's autonomy?

Follow facility protocol when performing a procedure on the client.

Administer pain medication on a routine schedule.

Keep an agreement made with the client to administer an antiemetic medication.

Include the client's input when setting treatment goals.

Answer and Explanation

The Correct Answer is D

Autonomy in healthcare refers to a client’s right to make informed decisions about their own care, including treatment preferences, goals, and end-of-life choices. In clients with terminal illness, respecting autonomy is especially important because care often shifts toward comfort, dignity, and individualized priorities. Nurses support autonomy by involving clients in decision-making, providing clear information, and honoring expressed wishes. This approach ensures care aligns with the client’s values rather than being solely provider-directed.

Rationale:
A. Following facility protocol when performing a procedure ensures safety and standardization of care, but it does not directly promote client autonomy. While protocols are important for consistency and risk reduction, they do not involve the client in decision-making or respect personal preferences.

B. Administering pain medication on a routine schedule promotes comfort and symptom control but is more related to beneficence than autonomy. It does not necessarily reflect the client’s participation in decisions about their care plan or treatment goals.

C. Keeping an agreement made with the client to administer an antiemetic medication demonstrates trust and reliability, but it primarily reflects fidelity rather than autonomy. While honoring agreements is important, it does not specifically involve the client in decision-making processes.

D. Including the client’s input when setting treatment goals directly supports autonomy by involving them in decisions about their care. In conditions such as Terminal cancer, this ensures care aligns with the client’s values, preferences, and desired quality of life. This shared decision-making is the clearest example of respecting and promoting autonomy.

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Correct Answer is D

Explanation

Informed consent for surgical procedures such as an emergency appendectomy requires legal authorization from the individual who has decision-making capacity. In the case of a 17-year-old client, the ability to consent depends on emancipation status, marital status, and legal recognition as an adult for healthcare decisions. Consent must be obtained from the person who is legally and cognitively able to understand the procedure, risks, benefits, and alternatives. This ensures respect for patient autonomy and legal compliance in surgical care.

Rationale:
A. The provider is responsible for explaining the procedure, risks, benefits, and alternatives, but does not sign the informed consent form. The provider’s role is to ensure the client is fully informed and competent to make a decision. Signing the form is not within the provider’s legal responsibility, even in emergency situations.

B. The client’s partner does not have legal authority to provide informed consent unless granted legal guardianship or power of attorney. Marriage alone does not automatically transfer decision-making rights for minors in all jurisdictions unless the minor is legally emancipated. Therefore, the partner cannot sign the consent form in this situation.

C. The client’s caregiver also does not have legal authority to provide informed consent unless they are the legally appointed guardian. Caregivers may provide support or input, but they cannot override the client’s autonomous decision-making rights if the client is legally able to consent. Their role is supportive rather than decisional.

D. The client is the appropriate individual to sign the informed consent form because marriage may confer legal emancipation status, depending on jurisdiction, granting them adult decision-making rights. An emancipated minor or legally recognized adult has the authority to consent to surgical procedures independently. The nurse should ensure the client understands the procedure and is mentally competent before witnessing the signature.

A. Glucagon injection B. 1 tsp of sugar C. Glass of orange juice D. 1 tsp of peanut butter

Correct Answer is C

Explanation

Management of hypoglycemia in a client with Type 1 diabetes mellitus involves rapid recognition and prompt administration of fast-acting carbohydrates to restore blood glucose levels. Mild hypoglycemia commonly presents with symptoms such as shakiness, sweating, hunger, irritability, or dizziness when blood glucose falls below normal levels. The priority treatment for a conscious client is administration of rapidly absorbable carbohydrates that can quickly raise serum glucose. Timely intervention helps prevent progression to severe neurological impairment or loss of consciousness.

Rationale:
A. Glucagon injection is typically reserved for severe hypoglycemia when the client is unconscious, unable to swallow safely, or experiencing seizures. Since the adolescent has only mild symptoms and is presumably alert enough to take oral carbohydrates, injectable glucagon is unnecessary at this stage. Oral treatment is preferred for mild hypoglycemic episodes.

B. One teaspoon of sugar alone does not provide an adequate amount of carbohydrate to effectively correct hypoglycemia. Standard treatment recommendations usually involve approximately 15 g of rapid-acting carbohydrate. A single teaspoon contains too little glucose and may not raise serum glucose sufficiently or rapidly enough.

C. A glass of orange juice is appropriate because it contains rapidly absorbed simple carbohydrates that quickly increase blood glucose levels. Fruit juice is commonly recommended for conscious clients experiencing mild hypoglycemia due to its fast onset of action. This intervention follows the “15-15 rule” commonly used in hypoglycemia management.

D. Peanut butter is not appropriate for immediate correction of hypoglycemia because its fat and protein content slows glucose absorption. Although it may help maintain glucose levels after initial correction, it does not act quickly enough to treat acute low blood sugar. Rapid-acting carbohydrates are needed first.

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A nurse is assisting in the care of a client who has terminal cancer. Which of the following actions should the nurse take to promote the client's autonomy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a 17-year-old client who is married and needs to undergo an emergency appendectomy. Which of the following Individuals should the nurse ask to sign the informed consent form?

Correct Answer is D

Explanation

A nurse is caring for an adolescent client who has type 1 diabetes mellitus. The adolescent reports mild symptoms and a serum glucose level of 55 g/dL. Which of the following should the nurse give the client?

Correct Answer is C

Explanation

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