A nurse is assisting with obtaining informed consent for a client who has been declared legally incompetent.
Which of the following actions should the nurse take?
Explain implied consent to the client's family.
Contact the facility social worker to obtain the consent.
Request that the client's guardian sign the consent.
Ask the charge nurse to obtain informed consent.
The Correct Answer is C
Choice A rationale:
Explaining implied consent to the client's family is not the appropriate action in this situation. Implied consent typically refers to situations where consent is assumed due to the client's actions or circumstances, but it is not applicable when a client has been declared legally incompetent. The nurse should seek consent from a legally authorized representative, such as a guardian, in this case.
Choice B rationale:
Contacting the facility social worker is a good step to take when dealing with complex legal and ethical situations. However, the nurse's primary responsibility is to ensure that the client's legally authorized representative provides informed consent. This means that the client's guardian should be the one to sign the consent form, rather than the social worker.
Choice D rationale:
Asking the charge nurse to obtain informed consent is not the appropriate action because obtaining consent is typically the responsibility of the healthcare provider or a legally authorized representative. The charge nurse may not have the legal authority to provide informed consent on behalf of the client.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D. Hyperthermia.
Choice A reason: Hyperglycemia, which is an elevated blood glucose level, is not typically a direct manifestation of alcohol withdrawal. Alcohol withdrawal can sometimes lead to poor oral intake or vomiting, which might indirectly affect blood sugar levels, but hyperglycemia itself is not a primary concern in the context of alcohol withdrawal.
Choice B reason: Decreased blood pressure During alcohol withdrawal, the sympathetic nervous system is often overactive, leading to symptoms such as increased blood pressure, rather than decreased. Therefore, decreased blood pressure is not a common manifestation of alcohol withdrawal. Normal blood pressure ranges for adults are systolic BP of 100-120mmHg and diastolic BP of 70-80mmHg.
Choice C reason: Decreased heart rate Similar to blood pressure, the heart rate typically increases during alcohol withdrawal due to sympathetic nervous system overactivity. A normal resting heart rate for adults ranges from 60 to 100 beats per minute (bpm). Decreased heart rate is not expected during alcohol withdrawal.
Choice D reason: Hyperthermia, or elevated body temperature, is a common symptom of alcohol withdrawal. This occurs as part of the body’s response to the sudden absence of alcohol, and can be a part of the withdrawal syndrome, which includes a range of symptoms from mild anxiety to severe complications like seizures. Normal body temperature ranges from 97°F (36.1°C) to 99°F (37.2°C).
Correct Answer is A
Explanation
Choice A rationale:
"Snap a rubber band on your wrist when you think about checking the locks.”. This choice suggests using a painful stimulus (the rubber band snap) as part of the thought-stopping technique. While it may interrupt the client's behavior temporarily, it is not a recommended or ethical approach, as it can cause harm and distress to the client.
Choice B rationale:
"Keep a journal of how often you check the locks each night.”. Keeping a journal may be useful for tracking behavior patterns, but it doesn't address the core issue of obsessive-compulsive disorder. It is essential to provide the client with a more active technique for managing their compulsions, like the one mentioned in choice C.
Choice D rationale:
"Ask a family member to check the locks for you at night.”. This choice does not promote independence or self-management, which is an important goal in treating obsessive-compulsive disorder. It may alleviate the client's anxiety temporarily but does not help the client develop skills to manage their obsessive-compulsive tendencies on their own.
Choice C rationale:
"Focus on abdominal breathing whenever you go to check the locks.”. This response is the most appropriate because it recommends a self-soothing and grounding technique (abdominal breathing) to help the client manage their obsessive thoughts and compulsions. It encourages the client to be more mindful and reduce the urge to perform repetitive behaviors, which is a key aspect of treating obsessive-compulsive disorder. .
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