A client with delusions tells the nurse, "You aren't doing your job.
Go get those people over there and shoot them before they get me." Which statement is the nurse's best response?

 

Choice A rationale:

The nurse should respect the client's autonomy and right to make decisions about her own care. It is essential to honor the client's refusal of further treatment, and the nurse should communicate this to the family. In this situation, the client has the capacity to make her own decisions, and her wishes should be respected.

Choice B rationale:

Attempting to persuade the client to participate in the clinical trial for one month is not an appropriate approach. It disregards the client's autonomy and her right to refuse treatment. It's essential to respect the client's decision, and trying to convince her against her will is ethically and legally inappropriate.

Choice D rationale:

While it's important to ensure that the client fully understands the implications of her decision, doing so in front of her children may create additional pressure or discomfort for the client. The best approach is to have a private conversation with the client to assess her understanding and provide information or support as needed.

Choice A rationale:

Increasing the supplemental oxygen to 15 L/min via nasal cannula may seem like a logical step given the client’s low oxygen saturation. However, it’s important to note that oxygen therapy should be titrated carefully. Too much oxygen can lead to oxygen toxicity, which can cause cellular damage and worsen the client’s condition. Therefore, this is not the priority action.

Choice B rationale:

Notifying the health care provider of the client’s condition is the priority action. The client’s oxygen saturation is 88% on room air, which is below the normal range of 95% to 100%. This indicates that the client is not getting enough oxygen, which can lead to hypoxia and other serious complications. The health care provider needs to be informed immediately so that appropriate interventions can be initiated.

Choice C rationale:

Administering ibuprofen as ordered for fever is important, but it’s not the priority in this situation. While fever can indicate an infection, which could be contributing to the client’s low oxygen saturation, addressing the immediate issue of hypoxia is more critical.

Choice D rationale:

Obtaining a sputum culture from the client could provide valuable information about the type of bacteria causing the pneumonia and guide antibiotic therapy. However, this is not an immediate priority compared to addressing the client’s low oxygen saturation. In summary, while all these actions are important in caring for a client with pneumonia, the nurse must prioritize interventions based on their urgency and potential impact on the client’s health status. In this case, notifying the health care provider of the client’s condition is the most critical action.