A nurse is caring for a client who is scheduled for a procedure, but the client states that they no longer want to undergo the procedure. Which of the following actions should the nurse take?

Explain that the treatment is both safe and therapeutic.

Tell the client that the procedure is necessary.

Notify the client's loved ones of the client's refusal of the procedure.

Inform the client they have the right to refuse treatment.

Answer and Explanation

The Correct Answer is D

A. Explain that the treatment is both safe and therapeutic: Providing reassurance about the safety and effectiveness of the procedure may be informative, but it can unintentionally pressure the client to consent. It does not respect the client’s autonomy or support their right to make independent healthcare decisions.

B. Tell the client that the procedure is necessary: Telling the client a procedure is necessary can sound coercive and may disregard their legal and ethical right to refuse treatment. Nurses must prioritize respecting the client's decisions, even if those decisions involve refusing recommended medical care.

C. Notify the client's loved ones of the client's refusal of the procedure: Informing family members without the client’s consent may breach confidentiality and is not appropriate unless the client is unable to make informed decisions. Client autonomy must be preserved, and their refusal should be respected unless there is an immediate risk of harm.

D. Inform the client they have the right to refuse treatment: Clients have the legal and ethical right to refuse any medical intervention, even if it is life-sustaining. The nurse’s role includes advocating for the client’s autonomy, ensuring informed consent, and supporting their decision without judgment or pressure.

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Correct Answer is D

Explanation

A. The client is sedentary throughout most of the day: While physical inactivity can lead to health issues such as muscle weakness and cardiovascular problems, it is not immediately life-threatening and can be addressed through lifestyle interventions.

B. The client verbalizes regret about never marrying: This reflects emotional distress or social isolation, which is important, but it does not pose an urgent physical health risk requiring immediate attention.

C. The client has no living family: Although lacking family support can affect long-term care planning and emotional well-being, it is not the most immediate threat to the client’s health in this context.

D. The client has poorly fitting dentures: This is the priority because it directly affects the client’s ability to eat, leading to potential malnutrition, weight loss, and decline in overall health—issues particularly dangerous for older adults.

A. Apply a heating pad to the client's neck. B. Provide the client with dry clothing. C. Offer the client a warm beverage. D. Wrap the client in warm blankets.

Correct Answer is B

Explanation

A. Apply a heating pad to the client's neck: Direct application of heat to the skin, especially in localized areas like the neck, can cause rapid vasodilation, leading to a dangerous drop in blood pressure and potential cardiac complications. It also increases the risk of burns on cold-numbed skin.

B. Provide the client with dry clothing: Removing wet clothing and replacing it with dry garments is the first priority in managing hypothermia. Wet clothes accelerate heat loss through conduction and evaporation. Stopping further heat loss is essential before attempting active rewarming.

C. Offer the client a warm beverage: While offering warm fluids can help increase core temperature and provide comfort, it is not the first priority. This intervention is more appropriate after ensuring the client is dry and wrapped in warm coverings.

D. Wrap the client in warm blankets: Wrapping the client in warm blankets is a critical intervention for passive external rewarming. However, it comes after the initial step of removing wet clothes to prevent ongoing heat loss. Blankets are most effective once the source of heat loss has been eliminated.

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A nurse is caring for a client who is scheduled for a procedure, but the client states that they no longer want to undergo the procedure. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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