A client is considering having a tubal ligation and reports being uncertain about if it is the right thing to do. Which of the following actions should the nurse take?
Provide information about alternate birth control methods.
Ask if the client has discussed the decision with their partner.
Emphasize the benefits of having the procedure.
Discuss the client's feelings about the procedure.
The Correct Answer is D
Choice A rationale: Providing information about other birth control methods is appropriate after the nurse explores the client's uncertainty, as it ensures the client's decision-making process is supported by understanding all available options.
Choice B rationale: While involving a partner can be helpful, the nurse’s primary responsibility is to the client’s autonomy; asking this first may shift the focus away from the client’s personal concerns.
Choice C rationale: Emphasizing only the benefits is non-therapeutic and biased. The nurse must remain neutral and allow the client to weigh both the benefits and risks of a permanent procedure.
Choice D rationale: Active listening and exploring the client's feelings are the first steps in the nursing process to address uncertainty. This allows the client to clarify their values and reach an informed decision.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Reminding the staff members that viewing the electronic medical record of a celebrity client without proper authorization is a breach of confidentiality is the immediate action required in this situation. It addresses the ethical and legal concerns related to patient privacy and ensures that the staff members are reminded of their professional responsibilities.
Choice B rationale:
Discussing the issue with the nurse manager is a step that can be taken after addressing the immediate breach of confidentiality. While involving the manager is important for handling the situation more comprehensively, the first priority is to stop the unauthorized access.
Choice C rationale:
Requesting an administrative restriction on the client's record access is an option that can be considered, but it may not be the first step to take. Before implementing such a restriction, the breach of confidentiality should be addressed directly with the staff members involved.
Choice D rationale:
Preparing a memo for the facility ethics committee is not the initial action to take in response to the breach of confidentiality. This step might be appropriate for addressing systemic issues or policy changes related to confidentiality breaches, but it doesn't directly address the immediate situation at hand.
Correct Answer is A
Explanation
Choice A rationale:
The nurse's first priority in the event of a fire is the safety and well-being of the clients. Clients who are in immediate danger due to the fire should be assisted to a safe location as quickly as possible. This choice is supported by the principles of prioritizing client safety during emergencies.
Choice B rationale:
Closing doors and windows on the unit is a secondary action and comes after ensuring the safety of clients in immediate danger. While it can help contain the fire's spread, it should not be the nurse's first action, as it does not address the immediate risk to clients' lives.
Choice C rationale:
Attempting to extinguish the fire using an ABC fire extinguisher might be a consideration in emergency situations; however, the nurse's first responsibility is to ensure the safety of clients. The nurse should not put themselves or clients at risk by attempting to extinguish the fire before moving clients to safety.
Choice D rationale:
Discontinuing oxygen use for clients who can breathe without it is not the nurse's primary action during a fire emergency. While it's important to manage resources, such as oxygen, the immediate focus should be on evacuating clients from the danger zone.
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