The nurse is providing preoperative teaching to a patient to have an operation on their colon for cancer. The nurse should take which of the following actions regarding informed consent?
Ensure the patient has received all necessary information about the procedure.
Make sure the client is competent to give consent.
Give a complete description of the procedure.
Witness the informed consent.
Research a non-surgical alternative treatment for colon cancer.
The Correct Answer is D
Choice A reason: Ensuring the patient receives all necessary information is the physician’s responsibility, not the nurse’s. Informed consent involves explaining risks, benefits, and alternatives, impacting patient autonomy. The nurse’s role is to witness the consent, verifying the patient’s understanding and voluntary agreement, ensuring ethical and legal standards are met without delivering medical details.
Choice B reason: Assessing competence is typically the physician’s role, as it requires evaluating cognitive capacity, influenced by neurological or psychological factors. Nurses may observe mental status but do not formally determine competence. Witnessing consent ensures the patient’s voluntary agreement, aligning with ethical principles of autonomy, making this a secondary nursing responsibility.
Choice C reason: Giving a complete procedure description is the surgeon’s duty, as it requires detailed medical knowledge of risks and outcomes. Nurses reinforce education but focus on witnessing consent to confirm voluntary agreement. Providing medical details exceeds the nurse’s scope, potentially causing confusion or miscommunication, impacting the patient’s informed decision-making process.
Choice D reason: Witnessing informed consent is the nurse’s primary role, verifying the patient received and understood information from the physician and consents voluntarily. This upholds autonomy, ensuring the patient’s decision aligns with their values. The nurse’s signature confirms the process, protecting legal and ethical standards without requiring them to provide medical explanations.
Choice E reason: Researching non-surgical alternatives is outside the nurse’s scope during preoperative teaching. Physicians discuss treatment options, considering cancer stage and biology. Nurses focus on witnessing consent, ensuring the patient’s understanding and voluntary agreement, supporting autonomy without delving into medical research, which could delay or confuse the consent process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: The statement reflects acceptance, the final Kübler-Ross stage, where patients find peace with mortality. Bargaining involves negotiating for more time or conditions, driven by fear of loss. Acceptance reduces psychological stress, calming the limbic system, unlike bargaining, which seeks to delay death, making this incorrect for the bargaining stage.
Choice B reason: This statement represents anger, the second Kübler-Ross stage, where patients question fairness, activating emotional stress responses in the amygdala. Bargaining involves making deals to postpone death, not expressing frustration. Anger increases cortisol, reflecting emotional turmoil, while bargaining seeks control, making this statement incorrect for the bargaining stage.
Choice C reason: This statement indicates denial, the first Kübler-Ross stage, where patients reject the diagnosis, avoiding psychological distress. Bargaining involves negotiating for more time, accepting the reality but seeking delays. Denial suppresses emotional processing in the brain, while bargaining engages hope, making this statement incorrect for the bargaining stage.
Choice D reason: Bargaining, the third Kübler-Ross stage, involves negotiating for more time, like living to see a milestone (e.g., grandson’s birth). This reflects psychological coping to delay death, engaging hope and emotional regulation via the prefrontal cortex. This statement perfectly aligns with bargaining’s attempt to regain control over mortality, making it correct.
Correct Answer is ["A","B","D","E"]
Explanation
Choice A reason: Reduced skin turgor, a sign of fluid volume deficit, occurs due to decreased interstitial fluid, reducing skin elasticity. Dehydration from fluid loss impairs cellular hydration, slowing skin recoil. This is a key assessment finding, as it reflects low extracellular fluid volume, affecting tissue perfusion and requiring fluid replacement to restore homeostasis.
Choice B reason: Decreased blood pressure results from fluid volume deficit, reducing intravascular volume and cardiac output. Low fluid decreases venous return, triggering baroreceptors to signal sympathetic activation, though insufficient to maintain pressure. This is a critical sign, as it indicates compromised perfusion to organs, necessitating fluid resuscitation to restore hemodynamic stability.
Choice C reason: Increased urine output is incorrect, as fluid volume deficit reduces urine output due to decreased renal perfusion. The kidneys conserve fluid via antidiuretic hormone and renin-angiotensin-aldosterone system activation, concentrating urine. This sign does not correlate with dehydration, which typically presents with oliguria, making it an incorrect assessment finding.
Choice D reason: Increased heart rate (tachycardia) compensates for fluid volume deficit, as reduced blood volume lowers cardiac output. Sympathetic activation increases heart rate to maintain tissue perfusion despite low fluid. This is a key sign, reflecting the body’s attempt to compensate for hypovolemia, requiring fluid replacement to normalize cardiovascular function.
Choice E reason: Dry mouth and skin are classic signs of fluid volume deficit, as dehydration reduces salivary gland secretion and skin moisture. Low extracellular fluid impairs mucous membrane hydration and sweat production. These signs indicate systemic fluid loss, affecting cellular function and requiring documentation to guide fluid therapy for restoring hydration and tissue perfusion.
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