A nurse is caring for a client who is recovering from a stroke. The provider recommends an extracranial-intracranial bypass, but the client tells the nurse that he will not have the surgery. Which of the following actions should the nurse take?

Inform the client of the consequences of decreased cerebral circulation.

Initiate a mental health consultation to determine why the client refuses the surgery.

Discuss the client's concerns about having the surgery.

Provide the client with information on additional treatment options.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Informing the client of the consequences of decreased cerebral circulation is premature without understanding the client's specific reasons for refusing the surgery. Jumping to consequences might not address the underlying fears or concerns the client has, potentially leading to increased resistance or anxiety.

Choice B rationale:

Initiating a mental health consultation is a valuable step if the client's refusal appears to be influenced by psychological or emotional factors. However, before involving mental health professionals, it's important for the nurse to engage in a direct conversation with the client to explore their thoughts, fears, and reservations.

Choice C rationale:

Discussing the client's concerns about having the surgery is the most appropriate action in this scenario. Engaging in an open and nonjudgmental conversation allows the nurse to understand the client's perspective, provide information, clarify misconceptions, and address any fears or uncertainties. This approach respects the client's autonomy and promotes shared decision-making.

Choice D rationale:

Providing the client with information on additional treatment options might be premature if the client's main concern is related to the current recommended surgery. It's crucial to first address the client's specific reservations before exploring other treatment possibilities.

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Correct Answer is D

Explanation

Choice A rationale:

Giving change-of-shift report at the client's bedside is not appropriate due to privacy concerns. The client's room is not a private area for discussing their medical information, and other clients or visitors might overhear sensitive details. A more appropriate location, such as a designated nursing station, should be used for shift handoffs.

Choice B rationale:

Providing client information over the phone to callers identifying themselves as family is incorrect. Even if the caller identifies as family, the nurse cannot verify their identity over the phone. Sharing confidential client information without proper verification violates confidentiality policies and can compromise the client's privacy.

Choice C rationale:

Stating that the client cannot see their medical record because it is considered property of the facility is incorrect. Clients have the legal right to access their medical records under the Health Insurance Portability and Accountability Act (HIPAA). While the physical record might be owned by the facility, clients have the right to review their medical information.

Choice D rationale:

Access to client information is limited to direct care providers is the correct statement. Confidentiality requirements dictate that only authorized individuals involved in the client's care, treatment, or payment processes have access to their medical information. This helps protect the client's privacy and ensures that sensitive information is not disclosed to unauthorized parties.

A. A client who is in balanced skeletal traction. B. A client who had a total hip arthroplasty 3 days ago. C. A client who has a fractured femur with a new cast. D. A client who had a right above-the-knee amputation 24 hours ago.

Correct Answer is D

Explanation

The correct answer is choice D.

Choice A rationale:

“A client who is in balanced skeletal traction.” This client requires specialized orthopedic knowledge to manage the traction and monitor for complications. A nurse without orthopedic experience may not be familiar with the care required.

Choice B rationale:

“A client who had a total hip arthroplasty 3 days ago.” This client is likely to require specialized post-operative care, including pain management, mobility assistance, and monitoring for complications such as infection or dislocation. These tasks typically require specific orthopedic training.

Choice C rationale:

“A client who has a fractured femur with a new cast.” This client will require specialized care to manage the cast, monitor for complications such as compartment syndrome, and provide pain management. These tasks typically require specific orthopedic training.

Choice D rationale:

“A client who had a right above-the-knee amputation 24 hours ago.” This is the correct answer. While this client will require post-operative care, the care is likely to be similar to the post-operative care provided on a medical unit, such as pain management, wound care, and monitoring for complications. Therefore, a nurse from a medical unit could likely provide appropriate care for this client.

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A nurse is caring for a client who is recovering from a stroke. The provider recommends an extracranial-intracranial bypass, but the client tells the nurse that he will not have the surgery. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse manager is teaching about confidentiality requirements to the staff. Which of the following staff comments indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse from a medical unit is asked to work on an orthopedic unit. The medical nurse has no orthopedic experience. Which of the following clients should be assigned to the medical nurse?

Correct Answer is D

Explanation

A charge nurse is planning client care assignments for a unit. Which of the following tasks should the nurse assign to a licensed practical nurse (LPN)?

A hospice nurse is planning care for a client who does not have advance directives. Which of the following interventions should the nurse include in the plan of care?

A nurse is developing a plan of care for a school-age child whose family is homeless. Which of the following findings should the nurse identify as the priority?

A nurse is caring for a client who is comatose. The client has a living will that declines the use of artificial enteral nutrition as a life-sustaining measure, but the client's family has requested that the staff begin tube feedings. Which of the following actions should the nurse take?

A nurse is conducting an orientation class for new clients and their families at a long-term care facility. Which of the following client rights should the nurse address at the orientation? (Select all that apply.).

A client who has back pain presents to an emergency department and is provided a prescription for oxycodone. A staff nurse tells the charge nurse that they think the client is seeking drugs and is not actually in distress. Which of the following responses should the charge nurse make?

A nurse on a medical-surgical unit is caring for a client transferred from another department. The nurse should verify that the client has given informed consent prior to which of the following procedures?

A nurse is developing a discharge plan for a client who is postoperative and will require a wheelchair in the home. The nurse should place a referral to which of the following resources to assist the client with this need?