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?

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.

Encourage the client to have the procedure.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Obtaining consent from the client's family member is not the appropriate action in this scenario. The client has the right to make decisions about their own medical treatment, and the consent should come from the client themselves, not a family member.

Choice B rationale:

Informing the client that they have the legal right to refuse treatment at any time is the correct action. Informed consent is a fundamental principle of medical ethics, and the nurse should respect the client's autonomy and right to make decisions about their own healthcare.

Choice C rationale:

Requesting another nurse to review the procedure with the client may be helpful in providing additional information and support, but it does not address the client's right to refuse treatment. The primary responsibility is to ensure that the client is aware of their right to refuse.

Choice D rationale:

Encouraging the client to have the procedure goes against the principle of respecting the client's autonomy and right to make their own decisions about their healthcare. The nurse should not pressure the client into having the procedure.

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Correct Answer is A

Explanation

Choice A rationale:

Command hallucinations require immediate intervention by the nurse. Command hallucinations are auditory hallucinations in which the client hears voices instructing them to perform specific actions, often harmful or dangerous. These hallucinations can lead to the client engaging in harmful behaviors or self-harm. The nurse must address this symptom promptly to ensure the client's safety and well-being.

Choice B rationale:

Impaired memory is a common symptom in clients with delirium, but it does not require immediate intervention. While impaired memory can be distressing for the client, it is not an immediate safety concern. The nurse should address memory deficits as part of the overall care plan but prioritize more urgent issues like command hallucinations.

Choice C rationale:

Inappropriate speech patterns are also common in clients with delirium. While they may be concerning, they do not typically pose an immediate risk to the client's safety. The nurse should assess and address inappropriate speech patterns but prioritize the safety of the client, especially when command hallucinations are present.

Choice D rationale:

Rapid mood swings are a symptom of delirium but, like impaired memory and inappropriate speech patterns, do not require immediate intervention to the same extent as command hallucinations. The nurse should address mood swings as part of the overall care plan and ensure that the client's safety is not compromised due to their condition.

A. Refer the client to a self-help group. B. Teach the client to practice systematic desensitization. C. Request a discharge prescription for buprenorphine for the client. D. Contact a close relative of the client to discuss the discharge plan.

Correct Answer is A

Explanation

Refer the client to a self-help group.

Choice B rationale:

Teach the client to practice systematic desensitization. Systematic desensitization is a therapeutic technique primarily used for phobias and anxiety disorders. It is not a standard treatment for alcohol use disorder. While it might help with some aspects of anxiety related to substance abuse, it is not a core recommendation for this condition.

Choice C rationale:

Request a discharge prescription for buprenorphine for the client. Buprenorphine is typically prescribed for opioid use disorder, not alcohol use disorder. It is not an appropriate medication for treating alcohol addiction.

Choice D rationale:

Contact a close relative of the client to discuss the discharge plan. Involving a close relative in the discharge plan can be beneficial for providing social support and ensuring a safer transition. However, it is not the primary recommendation. Referring the client to a self-help group (Choice A) is more focused on addressing the alcohol use disorder directly.

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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?

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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?