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?

Encourage the client to have the procedure.

Obtain consent from the client's family member.

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

Request another nurse to review the procedure with the client.

Answer and Explanation

The Correct Answer is C

A.   Encouraging the client to have the procedure disregards their autonomy and right to refuse treatment.
B.   Obtaining consent from a family member is not appropriate if the client is capable of making their own decisions.
C.   Informing the client of their legal right to refuse treatment respects their autonomy and allows them to make an informed decision about their care.
D.   Requesting another nurse to review the procedure may be helpful for clarification but does not address the client's right to refuse treatment.

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Correct Answer is C

Explanation

A. Orientation to person, place, and time is important for assessing mental status but may not necessarily indicate the need for restraint removal.
B. Self-harm threats should be taken seriously but may require further assessment and intervention rather than immediate restraint removal.
C. The ability to follow commands indicates a level of cooperation and self-control, which may warrant removal of restraints as the client can potentially be managed without them.
D. Refusal to take medication may necessitate further intervention but may not directly indicate the need for restraint removal unless it poses an immediate risk to the client's safety.

A. Administer methadone hydrochloride. B. Monitor for orthostatic hypotension. C. Acidify the client's urine. D. Implement seizure precautions.

Correct Answer is D

Explanation

A. Methadone hydrochloride is not indicated for the management of alcohol intoxication or withdrawal. It is primarily used for opioid addiction treatment.
B. While monitoring for orthostatic hypotension is important in clients with alcohol use disorder, implementing seizure precautions is a higher priority because alcohol withdrawal can lead to
seizures.
C. Acidifying the client's urine is not indicated in the care of an intoxicated client with alcohol use disorder.
D. Implementing seizure precautions is essential in clients with alcohol use disorder who are at risk for alcohol withdrawal syndrome, which can include seizures as a potential complication.

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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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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?