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.

Request another nurse to review the procedure with the client.

Obtain consent from the client's family member.

Answer and Explanation

The Correct Answer is A

The nurse should respect the client's autonomy and inform them of their right to refuse treatment, even if it is against medical advice. The nurse should also explore the reasons for the refusal and provide information and support as needed. The other options are not appropriate as they do not respect the client's decision or may violate their privacy.

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Correct Answer is C

Explanation

A behavioral contract is a written agreement between the client and the nurse that specifies the desired and undesired behaviors and the rewards and penalties for each. A client who has antisocial personality disorder may exhibit impulsive, aggressive, and manipulative behaviors that disrupt the therapeutic milieu and interfere with treatment goals. Decreasing the number of verbal outbursts is a measurable and realistic goal that can improve the client's interpersonal skills and reduce conflict.

A. Obtain the provider's prescription within 60 min. B. Document the client's behavior every 15 min. C. Monitor the client's vital signs every 4 hr. D. Offer the client food and fluids every 2 hr.

Correct Answer is B

Explanation

Choice A reason:

Obtaining the provider's prescription within 60 min is not the immediate action required in this scenario. The priority is to ensure the safety of the client and others, which is achieved by continuous monitoring and documentation.

Choice B reason:

Documenting the client's behavior every 15 min is crucial in managing physically aggressive clients in seclusion. This allows the healthcare team to monitor the client's condition closely and make necessary interventions promptly.

Choice C reason:

Monitoring the client's vital signs every 4 hr may not be frequent enough for a client in seclusion who has been physically aggressive. The client's condition could change rapidly, and more frequent monitoring might be necessary.

Choice D reason:

Offering food and fluids every 2 hr is important for maintaining the client's physical health, but it is not the primary action in managing a physically aggressive client in seclusion. The immediate focus should be on ensuring safety and managing the client's aggressive behavior.

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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

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