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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Explanation
The nurse should first address the client’s heart rate followed by the client’s skin turgor.
Target 1: Heart Rate
Reason: The client’s heart rate is 44/min, which is significantly below the normal range of 60-100 beats per minute for adults. This condition, known as bradycardia, can be life-threatening and requires immediate medical attention. Bradycardia in anorexia nervosa patients is often due to malnutrition and electrolyte imbalances, which can lead to cardiac complications. Addressing the heart rate is crucial to stabilize the client’s cardiovascular system and prevent potential cardiac arrest.
Target 2: Skin Turgor
Reason: Skin turgor is an important indicator of hydration status. The client has decreased skin turgor, suggesting dehydration. Dehydration can exacerbate other medical conditions and lead to severe complications if not treated promptly. By addressing skin turgor, the nurse can help restore the client’s fluid balance, which is essential for overall health and recovery.
Choice A: Body Image
Reason: While body image is a significant psychological aspect of anorexia nervosa, it is not the immediate priority in this scenario. Addressing body image issues is crucial for long-term recovery and preventing relapse, but it does not pose an immediate threat to the client’s physical health. Psychological interventions can be initiated once the client’s critical physical health issues are stabilized.
Choice B: Lanugo
Reason: Lanugo, the fine hair that develops on the body, is a sign of severe malnutrition and the body’s attempt to conserve heat. While it indicates the chronic nature of the client’s condition, it is not an immediate threat to life. Addressing lanugo involves improving the client’s nutritional status over time, which will naturally resolve as the client’s health improves.
Choice C: Heart Rate
Reason: As previously mentioned, the client’s heart rate is critically low and poses an immediate risk to their life. Bradycardia must be addressed first to stabilize the client’s cardiovascular function and prevent life-threatening complications.
Choice D: Skin Turgor
Reason: Decreased skin turgor indicates dehydration, which can lead to severe complications if not corrected. Rehydration is essential for the client’s recovery and overall health, making it a priority after stabilizing the heart rate.
Choice E: Russell’s Sign
Reason: Russell’s sign, characterized by calluses on the knuckles from self-induced vomiting, is a physical indicator of the client’s purging behavior. While it is important to address the underlying behaviors associated with Russell’s sign, it is not an immediate threat to the client’s physical health. Behavioral interventions can be implemented once the client’s critical physical health issues are managed.
Correct Answer is A
Explanation
Choice A reason:
This statement indicates spiritual distress because it reflects a disruption in the client's spiritual practice due to the scheduling of therapy sessions. Meditation is often a crucial part of an individual's spiritual routine, providing a sense of peace, connection, and well-being. When such practices are interrupted, especially by factors outside one's control, it can lead to feelings of spiritual disconnection and distress.
Choice B reason:
While increased visits from a spiritual advisor could suggest a need for more support, it does not necessarily indicate spiritual distress. It could mean that the client is seeking additional guidance and comfort during illness, which is a common and proactive approach to maintaining spiritual health.
Choice C reason:
Gaining comfort from meditation is a positive statement reflecting that the client is able to find solace and spiritual support through their practice. This does not indicate spiritual distress; rather, it shows effective use of spiritual resources to cope with challenges.
Choice D reason:
Expressing that faith provides hope during difficult times is a sign of spiritual strength and resilience. This statement suggests that the client's spiritual beliefs are a source of support and do not reflect spiritual distress.
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