A nurse is assisting in the care of a client who is scheduled for surgery.

Exhibits

The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing. Select all that apply.

A. "We can discuss this after completing the admission process." Delaying discussion about the client’s aggression may leave the partner feeling unheard and unsupported during an emotionally charged moment. Immediate acknowledgement is important to build trust and provide reassurance.

B. "Your partner is in the denial stage of grief." Verbal aggression is not typically linked to the denial stage of grief, which is more about avoidance or disbelief. Aggression is more often related to frustration, fear, or physiological changes at end of life.

C. "You should discuss this problem with your family members." Redirecting the partner to family members does not address their concerns directly and can seem dismissive. The nurse should provide direct support and clear information to help the partner understand the client’s behavior.

D. "Your partner is experiencing an expected response to the dying process." Verbal aggression can be a normal reaction to the stress, pain, or neurological changes associated with the dying process. Providing this explanation helps normalize the behavior, reducing anxiety for the partner and promoting understanding.

A. Explain that the treatment is both safe and therapeutic: Providing reassurance about the safety and effectiveness of the procedure may be informative, but it can unintentionally pressure the client to consent. It does not respect the client’s autonomy or support their right to make independent healthcare decisions.

B. Tell the client that the procedure is necessary: Telling the client a procedure is necessary can sound coercive and may disregard their legal and ethical right to refuse treatment. Nurses must prioritize respecting the client's decisions, even if those decisions involve refusing recommended medical care.

C. Notify the client's loved ones of the client's refusal of the procedure: Informing family members without the client’s consent may breach confidentiality and is not appropriate unless the client is unable to make informed decisions. Client autonomy must be preserved, and their refusal should be respected unless there is an immediate risk of harm.

D. Inform the client they have the right to refuse treatment: Clients have the legal and ethical right to refuse any medical intervention, even if it is life-sustaining. The nurse’s role includes advocating for the client’s autonomy, ensuring informed consent, and supporting their decision without judgment or pressure.