A nurse is reviewing with another nurse a method of documentation that includes data, action, and response (DAR) when charting client care. Which of the following methods of documentation is the nurse referring to?

A. Witnessing a client consent for a surgical procedure. The nurse can act as a witness to the client’s signature on the informed consent form. This ensures that the client voluntarily agrees to the procedure without coercion. However, the nurse does not obtain informed consent, as that responsibility belongs to the provider performing the procedure.

B. Confirming that a client appears competent to consent to a surgical procedure. The nurse plays a role in assessing whether the client appears competent to provide consent. If the client is confused, disoriented, or under the influence of sedating medications, the nurse should notify the provider and ensure that legal and ethical protocols are followed.

C. Witnessing a client consent for a surgical procedure. The nurse’s role in informed consent includes witnessing the client’s signature, verifying the client's understanding, and ensuring that the client is making an informed, voluntary decision. This is within the scope of professional nursing practice.

D. Explaining the steps of a surgical procedure to a client. It is the responsibility of the provider performing the procedure to explain its risks, benefits, alternatives, and expected outcomes. When a nurse provides detailed explanations of a surgical procedure, it may be considered outside their scope of practice, leading to misinformation or legal liability.

A. Hypoglycemia. Acute pain does not directly cause hypoglycemia. While stress responses can influence blood sugar levels, pain typically triggers the release of catecholamines, which increase glucose levels rather than decrease them.

B. Bradycardia. Pain activates the sympathetic nervous system, leading to an increase in heart rate (tachycardia) rather than a decrease (bradycardia). Bradycardia is more commonly associated with parasympathetic activation or certain medications.

C. Decreased respiratory rate. Pain often causes an increase in respiratory rate (tachypnea) due to heightened sympathetic stimulation. A decreased respiratory rate would be more likely in cases of severe sedation or opioid overdose, not in response to acute pain.

D. Hypertension. Acute pain stimulates the release of stress hormones such as epinephrine and norepinephrine, leading to vasoconstriction and increased blood pressure. This is a common physiological response to pain as the body prepares to react to the perceived threat.