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 D

Explanation

A. Close-up of eyes with yellow sclera: Could indicate jaundice or liver dysfunction, which is not an expected part of aging and requires further evaluation.

B. Older adult man with a rounded back and head tilted forward: Suggests kyphosis, which can occur with aging but is usually linked to osteoporosis or vertebral fractures, not considered an inevitable, expected change.

C. Close-up of nose with a reddish-purple spot (possible bruise): Might result from trauma, coagulopathy, or medication side effects like anticoagulants, not a routine age-related change.

D. Hands with prominent veins, thin skin, and wrinkles: Thinning skin due to decreased subcutaneous fat. Wrinkles from reduced skin elasticity. Prominent veins due to loss of skin turgor and connective tissue. These are all normal physical findings in older adults.

A. The stoma protrudes slightly from the abdomen. B. The stoma bleeds lightly when touched. C. The stoma is draining a small amount of liquid stool. D. The stoma appears dark in color.

Correct Answer is D

Explanation

A. The stoma protrudes slightly from the abdomen: A stoma that protrudes slightly (about 1–2 cm) above the skin surface is normal and indicates healthy placement. This finding does not require reporting.

B. The stoma bleeds lightly when touched: Light bleeding with gentle palpation or cleaning is common due to the stoma’s rich blood supply and is generally not concerning unless bleeding is excessive.

C. The stoma is draining a small amount of liquid stool: Liquid stool drainage is expected from a colostomy, especially in the early postoperative period. This is a normal finding that does not require reporting.

D. The stoma appears dark in color: A dark, dusky, or black stoma indicates compromised blood flow and possible ischemia or necrosis. This is a serious finding that requires immediate reporting to prevent further complications.

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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 D

Explanation

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Correct Answer is D

Explanation

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