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?

Encourage the client to have the procedure.

Obtain consent from the client's family member.

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

Request another nurse to review the procedure with the client.

Answer and Explanation

The Correct Answer is C

A.   Encouraging the client to have the procedure disregards their autonomy and right to refuse treatment.
B.   Obtaining consent from a family member is not appropriate if the client is capable of making their own decisions.
C.   Informing the client of their legal right to refuse treatment respects their autonomy and allows them to make an informed decision about their care.
D.   Requesting another nurse to review the procedure may be helpful for clarification but does not address the client's right to refuse treatment.

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Correct Answer is B

Explanation

A. Oxygen saturation is not directly related to the client's reported consumption of pepperoni pizza and phenelzine.
B. Phenelzine is a monoamine oxidase inhibitor (MAOI), and consuming foods high in tyramine, such as pepperoni pizza, can lead to a hypertensive crisis. Therefore, assessing the client's blood pressure is essential to monitor for potential hypertensive effects.
C. Bowel sounds are not directly related to the client's reported consumption of pepperoni pizza and phenelzine.
D. Pupil response is not directly related to the client's reported consumption of pepperoni pizza and phenelzine.

A. "My faith gives me hope during difficult times." B. "Therapy is often scheduled during my daily meditation time." C. "I gain comfort from meditation." D. "My spiritual advisor has increased visits since I became ill."

Correct Answer is B

Explanation

- Choice A Rationale: This statement does not indicate spiritual distress. On the contrary, it suggests that the client's faith is a source of strength and hope, which is typically a sign of positive spiritual well-being.
- Choice B Rationale:

This statement suggests a disruption in the client's spiritual practices, which could lead to spiritual distress as it interferes with a meaningful coping mechanism.

- Choice C Rationale: Similar to choice A, this statement reflects a positive aspect of the client's spirituality. Finding comfort in meditation is indicative of a beneficial spiritual practice and does not suggest distress.
- Choice D Rationale:

This reflects active spiritual support, which is helpful during illness and not indicative of spiritual distress.

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Body system	Findings
Neurological	Impaired cognition

	Insomnia Seizures
Cardiovascular	Increased blood pressure Increased heart rate Diaphoresis
Gastrointestinal	Lack of appetite Vomiting
Musculoskeletal	Malaise Tremulousness

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

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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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?