A nurse is caring for a client who is scheduled for surgery. The client states, "I have decided not to have the surgery." Which of the following responses should the nurse make to the client?
"I don't think you understand the risks to your health."
"You should talk with your family about it first."
"I will notify your provider regarding this decision."
"Let me remind you of the benefits of the surgery."
The Correct Answer is C
Rationale:
A. "I don't think you understand the risks to your health.": This response is dismissive of the client’s autonomy and implies the nurse is questioning the client’s decision-making ability. It can create a defensive reaction rather than supporting informed consent.
B. "You should talk with your family about it first.": While family support can be helpful, the decision for surgery ultimately rests with the client. Suggesting family involvement at this point could undermine the client’s right to make an independent healthcare decision.
C. "I will notify your provider regarding this decision.": This response respects the client’s autonomy and ensures the healthcare team is promptly informed. It also facilitates further discussion between the provider and client about the decision, ensuring it is fully informed.
D. "Let me remind you of the benefits of the surgery.": While reviewing benefits can be part of informed consent, doing so after the client has expressed a clear decision not to proceed may be perceived as coercive rather than supportive.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. 1 cup sliced peaches: Peaches contain some vitamin C but in lower amounts compared with other fruits. They are not the highest source for meeting daily vitamin C needs in toddlers.
B. 1 cup sliced banana: Bananas provide minimal vitamin C and are better known for their potassium content. They are not an effective choice for significantly increasing vitamin C intake.
C. 1 cup sliced kiwifruit: Kiwifruit is exceptionally high in vitamin C, providing more than the daily requirement for a toddler in a single cup. It is an excellent choice for boosting vitamin C intake.
D. 1 cup cubed cantaloupe: Cantaloupe contains vitamin C but in moderate amounts. While beneficial, it is less concentrated than kiwifruit for meeting vitamin C needs.
Correct Answer is A
Explanation
Rationale:
A. Wear a gown while providing personal hygiene: Contact precautions are required for clients with Clostridium difficile to prevent transmission via contaminated surfaces or direct contact. Wearing a gown during personal care protects the nurse’s clothing and skin from spores.
B. Place the client in a room with negative airflow: Negative airflow rooms are required for airborne infections such as tuberculosis or measles. C. difficile is spread via the fecal–oral route and does not require airborne isolation measures.
C. Apply a mask when providing care: Masks are necessary for droplet or airborne pathogens, but C. difficile spores are transmitted through direct or indirect contact, not respiratory droplets, so masks are not routinely required unless there is another indication.
D. Wipe the stethoscope with alcohol after leaving the client's room: C. difficile spores are resistant to alcohol-based disinfectants. Cleaning equipment requires soap and water or a sporicidal disinfectant to effectively remove spores and prevent spread.
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