A nurse is caring for a client who has given informed consent for electroconvulsive therapy (ECT). Just before the procedure, the client expresses to the nurse that she is having second thoughts and is considering not going through with the treatment. What is the most appropriate response for the nurse in this situation?
"It's understandable to feel nervous before this treatment. Most people feel better after, but you have the right to change your mind at any time."
"I know this is a difficult decision, but the doctor believes ECT is the best option for you. Are you sure you want to cancel?"
"That's completely fine! We can reschedule for another time when you're feeling more ready."
"You signed the consent form, so you need to go through with the treatment. It's important to follow through on your commitments."
The Correct Answer is A
The correct answer is Choice A.
Choice A rationale:
- Acknowledges the client's feelings: It's important for the nurse to validate the client's concerns and let them know that it's understandable to feel nervous or uncertain about ECT.
- Provides information about the treatment: The nurse can offer information about the potential benefits of ECT, but it's important not to pressure the client or make them feel like they have to go through with it.
- Reassures the client of their right to change their mind: This is a crucial aspect of informed consent. The client has the right to withdraw their consent at any time, even after signing the consent form.
Choice B rationale:
- Places undue pressure on the client: This response implies that the doctor knows what's best for the client and that the client should go through with the treatment even if they have doubts. This can undermine the client's autonomy and decision-making ability.
Choice C rationale:
- May minimize the client's concerns: While rescheduling the treatment is an option, it's important to explore the client's concerns more thoroughly before suggesting this. It's possible that the client has valid reasons for not wanting to go through with ECT, and these reasons should be addressed.
Choice D rationale:
- Is disrespectful of the client's autonomy: This response suggests that the client is obligated to go through with the treatment simply because they signed a consent form. This ignores the fact that people can change their minds and that consent is an ongoing process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choiceb. Instruct the client to notify the provider if diarrhea develops.
Choice A rationale:
Infusing penicillin G over 10 minutes is not recommended as it may cause adverse reactions.The infusion rate should be based on the specific guidelines for the medication and patient condition.
Choice B rationale:
Diarrhea can be a sign of a serious side effect called Clostridium difficile-associated diarrhea, which can occur with antibiotic use.It is important for the client to notify the provider if this symptom develops.
Choice C rationale:
Penicillin G should be stored according to the manufacturer’s instructions, which typically do not include refrigeration after reconstitution.Incorrect storage can affect the medication’s efficacy.
Choice D rationale:
Checking for a sulfa allergy is not relevant for penicillin G administration.Sulfa allergies are related to sulfonamide antibiotics, not penicillins.
Correct Answer is C
Explanation
Hyperthermia is a condition in which the body temperature is abnormally high, usually due to exposure to heat, infection, or certain medications.
Hyperthermia can cause neurological complications, such as seizures, confusion, or coma. Therefore, the nurse should initiate seizure precautions for an adolescent who has hyperthermia to prevent injury and protect the airway.
Choice A is wrong because covering the adolescent with a thermal blanket would increase the body temperature and worsen hyperthermia. The nurse should remove excess clothing and use cooling measures, such as fans, ice packs, or cool fluids.
Choice B is wrong because submerging the adolescent’s feet in ice water would cause vasoconstriction and shivering, which would reduce heat loss and increase heat production. The nurse should avoid using extreme cold or ice water to cool the body.
Choice D is wrong because administering oral acetaminophen would not be effective for hyperthermia caused by non-infectious factors, such as heat exposure or medications.
Acetaminophen lowers the body temperature by reducing the hypothalamic set point, which is not altered in hyperthermia. Additionally, oral medications may be difficult to swallow or absorb in a hyperthermic patient.
Normal body temperature ranges from 36.5°C to 37.5°C (97.7°F to 99.5°F). Hyperthermia is defined as a body temperature above 38.5°C (101.3°F).
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