A nurse is caring for a client who is scheduled for surgery. The nurse’s role in regard to informed consent is which of the following?
Discussing alternate treatment options
Determining the client’s level of understanding about the procedure
Explaining the risks involved with the procedure
Ensuring the charge nurse is available to witness the signature on the consent form
The Correct Answer is D
Choice A reason: Discussing alternative treatments is the responsibility of the provider performing the procedure, as part of obtaining informed consent. The nurse should not provide the substantive risk–benefit analysis or alternative interventions, which could be considered practicing beyond scope or create conflicting information. The nurse supports the process by reinforcing education and facilitating questions to the provider but does not originate discussions of alternatives that inform consent.
Choice B reason: Assessing and determining the client’s understanding is central to the nurse’s role. The nurse verifies that the client can articulate, in their own words, the nature of the procedure, its purpose, expected outcomes, major risks, benefits, and alternatives, and that consent is voluntary. If gaps or misconceptions are identified, the nurse facilitates clarification by the provider before the client signs. This protects patient autonomy, ensures ethical standards, and upholds legal requirements for valid informed consent.
Choice C reason: Explaining procedural risks is the provider’s duty, as only the clinician performing the procedure can fully represent the risks, benefits, alternatives, and expected outcomes specific to the intervention. The nurse may reinforce understanding by encouraging questions or providing general support but should not be the primary source of risk disclosure. Doing so could misrepresent information or exceed scope, potentially invalidating consent if the provider has not adequately informed the client.
Choice D reason: Witnessing the signature can be performed by a qualified nurse who is present, not specifically the charge nurse. The emphasis is ensuring that the signer is the correct patient, they are consenting voluntarily, and the form is completed after adequate explanation by the provider. Delegating or insisting on a charge nurse is unnecessary and may delay care. The nurse present should witness per policy, while also verifying understanding and facilitating provider re-explanation if needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: A massive head injury with no responsiveness indicates nonsurvivable injury. In mass casualty triage, resources are directed to those who can benefit. This client would be categorized as expectant, not immediate.
Choice B reason: Severe stridor and tracheal deviation indicate airway obstruction and tension pneumothorax, both life-threatening emergencies. This client requires immediate intervention to secure the airway and prevent death. This is the highest priority.
Choice C reason: An open fracture is serious but not immediately life-threatening. The client is stable and can wait for treatment after airway emergencies are addressed.
Choice D reason: A small partial-thickness burn is minor and not life-threatening. This client is the lowest priority in triage.
Correct Answer is C
Explanation
Choice A reason: Asking “why” places the client on the defensive and implies judgment, which can shut down communication. “Why” questions often elicit rationalizations rather than diagnostic detail, and they are less effective than open, neutral prompts. In anxiety assessment, the nurse should prioritize characterizing onset, duration, triggers, severity, functional impairment, and associated symptoms. A neutral, time-focused question helps establish chronology and guides subsequent targeted assessment without assigning blame.
Choice B reason: This is a labeling and judgmental statement that violates therapeutic communication principles. It risks stigmatizing the client, exacerbating distress, and damaging rapport. Such phrasing can undermine trust and prevent accurate assessment. Therapeutic communication requires empathy, validation, and neutrality to facilitate disclosure of symptoms, stressors, and coping strategies. Judgments impede the nurse’s ability to gather clinically relevant information and formulate a safe, effective plan.
Choice C reason: Focusing on duration opens the door to a clinically useful timeline, clarifying whether symptoms are acute, subacute, or chronic. Duration informs differential diagnosis (e.g., adjustment-related anxiety versus generalized anxiety), helps identify precipitating events, and frames severity and functional impact. It also allows the nurse to explore patterns, exacerbating factors, and any recent changes in sleep, substance use, or stressors. This neutral, open prompt fosters rapport and supports a systematic assessment.
Choice D reason: Redirecting to parents presumes their involvement and may be culturally insensitive or irrelevant for a young adult. It can prematurely shift responsibility away from the nurse’s professional role in assessment and support. The priority is to assess the client’s current symptoms comprehensively and determine safety, impairment, and need for further evaluation. Involving family may be appropriate later, with consent, but it is not the first-line response for establishing a clinical picture.
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