A nurse is caring for a client who is about to undergo open-heart surgery. The client states that he is very nervous about the surgery. Which of the following responses should the nurse make?

Choice A Reason:

Supporting the client's wish to refuse prescribed medications is a direct demonstration of respecting the client's autonomy. Autonomy in nursing is the right to self-determination, where patients are provided with adequate information to make their own decisions based on their beliefs and values. By supporting the client's decision, the nurse acknowledges the client's capacity to make informed choices about their own health care, even if the choice is different from what the medical team suggests.

Choice B Reason:

Ensuring that the client understands expectations for participation is more about informed consent and education rather than autonomy. While it is related to autonomy, it does not directly demonstrate the ethical concept since it does not involve a decision made by the client.

Choice C Reason:

Explaining unit rules and policies about unacceptable behaviors is part of the education process and setting boundaries within the healthcare environment. This action is necessary for all clients but does not specifically address the client's autonomy in making personal health decisions.

Choice D Reason:

Encouraging client feedback about satisfaction with the facility experience is a way to involve clients in the evaluation process of the facility's services. While this can be seen as respecting the client's opinions, it is not a direct action of supporting the client's autonomous decisions regarding their treatment plan

Choice A Reason:
Directly telling a client that their delusions are not real is not typically recommended. This approach can be confrontational and may lead to increased anxiety or agitation in the client. It's important to maintain a therapeutic relationship by validating the client's feelings and working within their current reality, rather than directly challenging their perceptions.

Choice B Reason:
Using frequent touch to provide support may not be appropriate for all clients, especially those with schizophrenia who may have altered perceptions of reality. Some individuals may find touch comforting, while others may perceive it as threatening or invasive. It's crucial to assess each client's comfort level with physical contact and proceed accordingly.

Choice C Reason:
Placing a client in seclusion can be a traumatic experience and is generally considered a last resort when other interventions have failed and the client is a danger to themselves or others. Seclusion should not be used solely because a client is experiencing visual hallucinations.

Choice D Reason:
Limiting the number of questions during assessments can help reduce the potential for overwhelming the client. Clients with schizophrenia may have difficulty processing too much information at once, and a barrage of questions can be stressful. Simplifying communication and allowing the client to focus on one question at a time can be more effective.