A nurse is caring for a client who is scheduled for a surgical procedure and states, "I don't want to have this surgery anymore." Which of the following responses should the nurse make?
"You have the right to refuse the procedure."
"We can manage your care following the procedure without complications."
"Your doctor thinks this surgery is necessary."
"Let me review the procedure so you can understand what is going to happen."
The Correct Answer is A
A. "You have the right to refuse the procedure.": Clients have the legal and ethical right to refuse treatment at any time, including surgery. Acknowledging this respects the client’s autonomy and supports informed decision-making.
B. "We can manage your care following the procedure without complications.": This statement minimizes the client’s concerns and may be perceived as coercive. It does not address the client’s right to make an informed choice.
C. "Your doctor thinks this surgery is necessary.": Referencing the provider’s opinion without exploring the client’s concerns does not respect the client’s autonomy and may increase anxiety or pressure to comply.
D. "Let me review the procedure so you can understand what is going to happen.": While providing information is helpful, the client has already expressed refusal. This approach may be more appropriate if the client is undecided, but it does not acknowledge their right to decline.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Urinary output 20 mL/hr: A urinary output less than 30 mL/hr in an adult indicates potential renal hypoperfusion or urinary retention. This is a priority finding that should be reported to the provider promptly.
B. Serous drainage on abdominal dressing: Serous drainage is a normal postoperative finding, indicating normal wound healing and fluid exudate. It does not require immediate provider notification.
C. Temperature 37.6° C (99.7° F): This temperature is slightly elevated but within the expected postoperative range due to the inflammatory response. It does not indicate an urgent complication.
D. Blood pressure 100/70 mm Hg: This blood pressure is within normal limits for many adults and is not necessarily concerning in a postoperative context unless accompanied by other symptoms such as tachycardia or dizziness.
Correct Answer is B
Explanation
A. Observe the client's range of movement: While monitoring physical status is important, mechanical restraints restrict movement, so assessing the client’s psychological triggers and safety is higher priority to prevent further aggression.
B. Identify stressors that caused the client's aggression: Understanding and addressing the factors that led to aggressive behavior is essential while the client is in restraints. This assessment helps in developing strategies to reduce agitation and prevent future episodes.
C. Hold a critical incident debriefing about the client: Debriefing is conducted after the event to support staff and evaluate interventions. It is not performed while the client is actively restrained.
D. Maintain sensory stimulation for the client: Providing excessive sensory stimulation during restraint can increase agitation and risk of injury. The focus should be on calming the client and ensuring safety rather than maintaining stimulation.
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