A physician orders a nasogastric (NG) tube for a young adult diagnosed with end-stage ovarian cancer and suspected of having a bowel obstruction. The newly hired nurse explains the procedure and rationale for NG tube placement. The client refuses to consent to NG tube placement, stating, "I would rather keep vomiting than have the tube in my nose." Following the American Nurses Association Code of Ethics for Nurses, what should the nurse do next?

Delegate the NG tube placement to a more experienced nurse.

Make a referral to Social Services related to body image disturbance.

Seek the client's spouse for consent to the procedure.

Document the client's wishes and notify the physician.

Answer and Explanation

The Correct Answer is D

Choice A reason : Delegating the NG tube placement to a more experienced nurse does not address the client's refusal of the procedure. The nurse must respect the client's autonomy and decision-making rights.

Choice B reason : While a referral to Social Services may be appropriate in some cases, it does not directly address the immediate concern of the client's refusal of the NG tube placement.

Choice C reason : Seeking consent from the client's spouse is not appropriate as the client is competent and has the right to refuse treatment. The client's autonomy must be respected.

Choice D reason : Documenting the client's wishes and notifying the physician is the correct action. The nurse must respect the client's right to refuse treatment and communicate this decision to the physician so that alternative management can be considered.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Choice A reason : Conducting 15-minute checks can be part of the safety measures for a client at risk of self-harm, but it may not be sufficient for someone who is actively hearing voices commanding self-harm and refusing to engage in safety planning. These checks are less intensive and may not provide the immediate intervention needed to ensure the client's safety¹.

Choice B reason : Encouraging the client to express feelings related to suicide is an important therapeutic intervention that can provide insight into the client's emotional state and risk factors. However, if the client is actively psychotic and not engaging in safety planning, this approach alone may not be enough to ensure immediate safety¹.

Choice C reason : Placing the client on one-to-one observation is the most direct and immediate intervention to ensure safety when a client is experiencing psychotic features and is at risk of self-harm. This level of observation means that the client is never alone, and a staff member is always present to intervene if the client attempts self-harm¹.

Choice D reason : Obtaining an order for locked seclusion can be considered if other less restrictive measures are not sufficient to ensure the client's safety. However, it is generally a last resort due to the potential for negative psychological effects and should only be used when absolutely necessary and when other interventions have failed¹.

A. Encourage interaction with others by having the client share a room with other clients. B. Provide a calm atmosphere by placing the client in a private room. C. Create a cheerful environment by having bright drapes in the client's room. D. Promote access to activities by assigning the client to a room near the dayroom.

Correct Answer is B

Explanation

Choice A reason: Encouraging interaction with others by having the client share a room might be overwhelming for a client experiencing hypomanic episodes. Hypomania can involve irritability and impulsivity, making shared spaces potentially stressful. It's important to balance social interaction with the need for a controlled environment¹.

Choice B reason: Providing a calm atmosphere by placing the client in a private room can be beneficial for someone experiencing hypomanic episodes. A private room can reduce overstimulation and help manage symptoms like restlessness, agitation, and sleep disturbances. It allows the client to have a quiet space to retreat to, which can be crucial in managing mood swings¹².

Choice C reason: While a cheerful environment may seem beneficial, having bright drapes in the client's room could potentially contribute to overstimulation. Clients with hypomania are often sensitive to environmental stimuli, so it's important to keep the setting subdued to avoid exacerbating symptoms¹.

Choice D reason: Promoting access to activities by assigning the client to a room near the dayroom can be a double-edged sword. While it facilitates engagement in structured activities, which can be therapeutic, it also increases the risk of overstimulation due to the proximity to a potentially busy and noisy area. Careful consideration of the client's current state is necessary when making this decision¹.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with major depressive disorder with psychotic features hears voices commanding self-harm. The client refuses to commit to developing a plan for safety. What should be the nurse's priority intervention at this time?

Correct Answer is C

Explanation

A nurse identifies that the environment is important when caring for a client with hypomanic episodes. What should the nurse do when caring for clients with this disorder?

Correct Answer is B

Explanation

A nurse is reviewing laboratory values for a client who has systemic lupus erythematosus (SLE). Which of the following values should give the nurse the best indication of the client's renal function?

A nurse is caring for a client who has thrombophlebitis and is receiving heparin by continuous IV infusion. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse give?

A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate?

A nurse is reviewing the health history of a client who has angina pectoris and a prescription for propranolol hydrochloride PO 40 mg twice daily. Which of the following findings in the history should the nurse report to the provider?

A nurse in a drug and alcohol detoxification center is planning care for a client who has alcohol use disorder and is currently in withdrawal. Which of the following interventions should the nurse identify as the priority?

Which patient is most likely experiencing a pulmonary embolism (PE)?

A nurse is caring for a client who is unable to make any decisions for themselves and needs constant reassurance. The nurse should identify that these are manifestations of which of the following personality disorders?

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?