A nurse is caring for a client who is scheduled for a procedure, but the client states that they no longer want to undergo the procedure. Which of the following actions should the nurse take?

Explain that the treatment is both safe and therapeutic.

Tell the client that the procedure is necessary.

Notify the client's loved ones of the client's refusal of the procedure.

Inform the client they have the right to refuse treatment.

Answer and Explanation

The Correct Answer is D

A. Explain that the treatment is both safe and therapeutic: Providing reassurance about the safety and effectiveness of the procedure may be informative, but it can unintentionally pressure the client to consent. It does not respect the client’s autonomy or support their right to make independent healthcare decisions.

B. Tell the client that the procedure is necessary: Telling the client a procedure is necessary can sound coercive and may disregard their legal and ethical right to refuse treatment. Nurses must prioritize respecting the client's decisions, even if those decisions involve refusing recommended medical care.

C. Notify the client's loved ones of the client's refusal of the procedure: Informing family members without the client’s consent may breach confidentiality and is not appropriate unless the client is unable to make informed decisions. Client autonomy must be preserved, and their refusal should be respected unless there is an immediate risk of harm.

D. Inform the client they have the right to refuse treatment: Clients have the legal and ethical right to refuse any medical intervention, even if it is life-sustaining. The nurse’s role includes advocating for the client’s autonomy, ensuring informed consent, and supporting their decision without judgment or pressure.

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Correct Answer is A

Explanation

A. Oriented to person only indicates the client is confused about time, place, or situation, which increases the risk of injury due to impaired judgment and decreased awareness of surroundings. This cognitive impairment can lead to unsafe behaviors like attempting to get out of bed unassisted or wandering.

B. Hearing acuity intact helps the client receive verbal instructions and alarms, reducing injury risk by facilitating communication and timely responses to safety cues. Good hearing supports situational awareness, which is protective against accidents.

C. Ability to use call light allows the client to summon assistance when needed, helping prevent falls or other injuries. This functional independence in communication is a key safety factor in the acute care setting.

D. Full range of motion in bilateral lower extremities indicates good physical mobility and strength, which decreases injury risk by enabling the client to reposition safely and maintain balance during transfers or ambulation.

A. The client holds the cane on the stronger side of their body. B. The client advances the cane forward 12.7 cm (5 in). C. The client moves their stronger leg forward first. D. The top of the cane is at the same height as the client's waist.

Correct Answer is A

Explanation

A. The client holds the cane on the stronger side of their body: Holding the cane on the stronger side improves balance and support while reducing strain on the weaker limb. It also helps coordinate movement and distribute weight more efficiently during ambulation.

B. The client advances the cane forward 12.7 cm (5 in): The cane should typically be advanced 15 to 25 cm (6 to 10 inches) forward for optimal support. Advancing it only 5 inches may provide insufficient balance assistance during walking.

C. The client moves their stronger leg forward first: The weaker leg should move forward after the cane to allow the stronger leg to support most of the weight. This pattern maximizes stability and safety during ambulation.

D. The top of the cane is at the same height as the client's waist: The cane should be level with the wrist crease when the client’s arms are relaxed at their sides, not at waist level. A cane that is too high or low can cause discomfort or improper posture.

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A nurse is caring for a client who is scheduled for a procedure, but the client states that they no longer want to undergo 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 A

Explanation

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