A nurse is caring for a client who has an anxiety disorder and is scheduled for a procedure. The client informs the nurse that they do not want to have the procedure. Which of the following actions should the nurse take?

Inform the client that they have the legal right to refuse treatment at any time.

Encourage the client to have the procedure.

Obtain consent from the client's family member.

Request another nurse to review the procedure with the client.

Answer and Explanation

The Correct Answer is A

Choice A reason:
It is essential to respect the client's autonomy and right to make decisions about their own health care. Informing the client of their legal right to refuse treatment empowers them to make an informed choice and ensures that their rights are upheld. The nurse should also explore the client's concerns and provide support and information to help alleviate any anxiety related to the procedure.

Choice B reason:
While it may be beneficial for the client's health to have the procedure, the nurse should not simply encourage the procedure without addressing the client's concerns. The nurse's role includes providing information and support to help the client make an informed decision, rather than persuading them to agree to the procedure.

Choice C reason:
Obtaining consent from a family member is not appropriate unless the client is legally unable to make their own medical decisions. The client's right to consent or refuse treatment should be respected, and the nurse should work directly with the client to address their concerns and provide necessary information.

Choice D reason:
Requesting another nurse to review the procedure with the client may be helpful if the client is seeking additional information or if there is a communication barrier. However, this should not replace the client's right to refuse treatment. The primary action should be to inform the client of their rights and address their concerns directly.

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Correct Answer is ["A","C","D","F","G"]

Explanation

Choice A: Gastrointestinal assessment
The client reports weight loss and minimal appetite over the past 3 months. This is significant because chronic alcohol use can lead to malnutrition, gastrointestinal issues, and liver damage. Weight loss and poor appetite may indicate underlying conditions such as gastritis, pancreatitis, or liver disease, which require further evaluation and intervention.
Choice B: Smoking history
The client quit smoking over 20 years ago and has no current respiratory issues. While smoking history is important for a comprehensive health assessment, it does not require immediate follow-up in this context as it is not directly related to the current acute issues of alcohol intoxication and potential withdrawal.
Choice C: Blood alcohol level
The client’s blood alcohol level (BAC) is 310 mg/dL, which is significantly elevated (normal range: 0 to 50 mg/dL). This level of intoxication can lead to severe complications such as respiratory depression, aspiration, and even death. Immediate medical intervention is necessary to manage the acute effects of alcohol intoxication and to monitor for withdrawal symptoms.
Choice D: Client’s recent loss
The recent death of the client’s parents is a significant emotional stressor that has contributed to the relapse of alcohol use disorder. Addressing this loss is crucial for the client’s mental health and recovery process. The nurse should ensure that the client receives appropriate psychological support and counseling to cope with this loss1.
Choice E: Genitourinary assessment
The client reports no known genitourinary problems. Therefore, this area does not require immediate follow-up in the context of the current admission for alcohol use disorder.
Choice F: Client’s recent consumption of alcohol
The client had their last drink 2 hours ago. This information is critical for monitoring potential alcohol withdrawal symptoms, which can begin within a few hours after the last drink and can be life-threatening if not properly managed. Close monitoring and timely intervention are essential
Choice G: Neurological assessment
The client is intoxicated, has slurred speech, and is unable to coherently respond to questions. These neurological symptoms indicate significant alcohol intoxication and the potential for withdrawal symptoms. Continuous neurological assessment is necessary to monitor for any changes in mental status and to prevent complications.
Choice H: Cardiac assessment
The client has a normal sinus rhythm and palpable pulses with no history of heart disease. While cardiac assessment is always important, there are no immediate concerns in this context that require follow-up.
Choice I: Respiratory assessment
The client’s respiratory rate is 10/min, which is on the lower end of normal (normal range: 12-20/min). However, the client has clear lungs and no shortness of breath. While respiratory status should be monitored, it is not an immediate concern requiring follow-up in this context.

A. The client has trouble remembering prescribed food restrictions. B. The client reports frustration with finding an activity to relieve restless energy. C. The client will be unable to return home after discharge. D. The client asks to talk to someone about changes in their spiritual beliefs.

Correct Answer is C

Explanation

Choice A reason:
While it is important for a social worker to be aware of a client's difficulty with remembering prescribed food restrictions, this information is more relevant to the dietary staff or a nutritionist who can assist with meal planning and education. However, if the memory issues are severe and impact the client's ability to live independently, then it would also be pertinent for the social worker.

Choice B reason:
Frustration with finding an activity to relieve restless energy may be relevant to a social worker if it pertains to the client's overall mental health and well-being. The social worker can collaborate with the healthcare team to find suitable activities or therapies that can help the client manage their energy levels.

Choice C reason:
The inability of the client to return home after discharge is critical information for a social worker. This directly impacts the client's need for support services, such as long-term care planning, home health services, or alternative living arrangements. The social worker plays a key role in coordinating these services and ensuring a smooth transition from the hospital to the next phase of care.

Choice D reason:
A request to talk to someone about changes in spiritual beliefs is also relevant to the social worker, as they can provide or arrange for spiritual support services. However, this is not as urgent as the need for housing or care planning, which has immediate practical implications for the client's discharge planning.

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A nurse is caring for a client who has an anxiety disorder and is scheduled for a procedure. The client informs the nurse that they do not want to have the procedure. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a mental health facility is admitting a client. Exhibits A nurse is caring for a client who was admitted for alcohol use disorder. Which of the following findings require follow-up by the nurse? Select all that apply.

Correct Answer is ["A","C","D","F","G"]

Explanation

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Correct Answer is C

Explanation

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