A nurse is assisting with obtaining informed consent for a client who has been declared legally incompetent. Which of the following actions should the nurse take?

Ask the charge nurse to obtain informed consent.

Contact the facility social worker to obtain the consent.

Explain implied consent to the client's family.

Request that the client's guardian sign the consent.

Answer and Explanation

The Correct Answer is D

The rationale is that a client who is legally incompetent cannot give informed consent, and the nurse should obtain consent from the person who has the legal authority to make decisions for the client, such as a guardian or a durable power of attorney.

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Correct Answer is B

Explanation

The client's statement reflects a loss of interest and pleasure in life, which is a major symptom of clinical depression. The other statements are normal expressions of grief that do not necessarily indicate depression, although they may warrant further assessment and support from the nurse.

A. Obtain the provider's prescription within 60 min. B. Document the client's behavior every 15 min. C. Monitor the client's vital signs every 4 hr. D. Offer the client food and fluids every 2 hr.

Correct Answer is B

Explanation

Choice A reason:

Obtaining the provider's prescription within 60 min is not the immediate action required in this scenario. The priority is to ensure the safety of the client and others, which is achieved by continuous monitoring and documentation.

Choice B reason:

Documenting the client's behavior every 15 min is crucial in managing physically aggressive clients in seclusion. This allows the healthcare team to monitor the client's condition closely and make necessary interventions promptly.

Choice C reason:

Monitoring the client's vital signs every 4 hr may not be frequent enough for a client in seclusion who has been physically aggressive. The client's condition could change rapidly, and more frequent monitoring might be necessary.

Choice D reason:

Offering food and fluids every 2 hr is important for maintaining the client's physical health, but it is not the primary action in managing a physically aggressive client in seclusion. The immediate focus should be on ensuring safety and managing the client's aggressive behavior.

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A nurse is assisting with obtaining informed consent for a client who has been declared legally incompetent. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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