A nurse is caring for a client who has an anxiety disorder and is scheduled for a procedure. The client informs the nurse that they do not want to have the procedure. Which of the following actions should the nurse take?

Inform the client that they have the legal right to refuse treatment at any time.

Encourage the client to have the procedure.

Obtain consent from the client's family member.

Request another nurse to review the procedure with the client.

Answer and Explanation

The Correct Answer is A

Choice A reason:
It is essential to respect the client's autonomy and right to make decisions about their own health care. Informing the client of their legal right to refuse treatment empowers them to make an informed choice and ensures that their rights are upheld. The nurse should also explore the client's concerns and provide support and information to help alleviate any anxiety related to the procedure.

Choice B reason:
While it may be beneficial for the client's health to have the procedure, the nurse should not simply encourage the procedure without addressing the client's concerns. The nurse's role includes providing information and support to help the client make an informed decision, rather than persuading them to agree to the procedure.

Choice C reason:
Obtaining consent from a family member is not appropriate unless the client is legally unable to make their own medical decisions. The client's right to consent or refuse treatment should be respected, and the nurse should work directly with the client to address their concerns and provide necessary information.

Choice D reason:
Requesting another nurse to review the procedure with the client may be helpful if the client is seeking additional information or if there is a communication barrier. However, this should not replace the client's right to refuse treatment. The primary action should be to inform the client of their rights and address their concerns directly.

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Correct Answer is D

Explanation

Choice A reason:
A client who is experiencing stimulant withdrawal may exhibit symptoms such as fatigue, depression, and increased appetite. While these symptoms can be distressing, they do not typically include seizures. Stimulant withdrawal does not usually necessitate seizure precautions because the risk of seizures is low.

Choice B reason:
A client who is experiencing opioid withdrawal may suffer from symptoms like anxiety, muscle aches, sweating, and nausea. Although opioid withdrawal can be very uncomfortable and distressing, it is not commonly associated with seizures. Therefore, seizure precautions are generally not required for opioid withdrawal.

Choice C reason:
A client who is experiencing cannabis withdrawal might experience irritability, sleep disturbances, and decreased appetite. Cannabis withdrawal is not typically associated with seizures, so seizure precautions are not necessary for these clients.

Choice D reason:
A client who is experiencing alcohol withdrawal is at a significant risk for seizures. Alcohol withdrawal can lead to severe complications such as delirium tremens, which includes symptoms like confusion, hallucinations, and seizures. Implementing seizure precautions for clients undergoing alcohol withdrawal is crucial to prevent injury and manage potential seizures effectively.

A. "All of your letters come sealed, so that seems unlikely." B. "You know that's not true, because it is against the law for others to read your mail." C. "It must be frightening to think that someone is reading your mail." D. "Why do you think the government wants to read your mail?"

Correct Answer is C

Explanation

Choice A reason:
Responding with "All of your letters come sealed, so that seems unlikely" dismisses the client's feelings and does not address their distress. Clients with delusions need validation of their emotions rather than logical arguments that contradict their beliefs.

Choice B reason:
Telling the client "You know that's not true, because it is against the law for others to read your mail" also dismisses their feelings and may increase their distress. Clients with delusions often hold their beliefs strongly, and simply stating that their belief is false does not help in managing their anxiety or fear.

Choice C reason:
Saying "It must be frightening to think that someone is reading your mail" validates the client's feelings and shows empathy. This response acknowledges the client's fear and opens the door for further discussion about their concerns. It is important to build trust and provide emotional support to clients experiencing delusions.

Choice D reason:
Asking "Why do you think the government wants to read your mail?" can reinforce the delusion by encouraging the client to elaborate on their false beliefs. This approach is not helpful in managing delusions and can lead to further distress.

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A nurse is caring for a client who has an anxiety disorder and is scheduled for a procedure. The client informs the nurse that they do not want to have the procedure. Which of the following actions should the nurse take?

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