A nurse is caring for a client who refuses a blood transfusion. Which of the following actions should the nurse take?

Inform the client that the transfusion is mandatory.

Document the client's refusal in the medical record.

Notify risk management about the client's refusal.

Suggest that the client explore alternative therapies.

Answer and Explanation

The Correct Answer is B

A) Inform the client that the transfusion is mandatory: This approach is not appropriate, as it disregards the client's autonomy and right to make informed decisions about their own healthcare. Patients have the right to refuse treatment, including blood transfusions.

B) Document the client's refusal in the medical record: This is the correct action. It is essential to document the client's decision thoroughly, including the discussion surrounding the refusal and any information provided about the risks and benefits of the transfusion. This documentation protects both the client and the healthcare team.

C) Notify risk management about the client's refusal: While it may be necessary to inform risk management in certain cases, it is not a standard procedure for all refusals of treatment. The focus should be on respecting the client's wishes first and ensuring proper documentation.

D) Suggest that the client explore alternative therapies: While it is important to provide clients with information about their options, suggesting alternative therapies should not take precedence over respecting the client's decision. Instead, the nurse should ensure the client is fully informed about the implications of their refusal and provide support in understanding their choices.

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Correct Answer is B

Explanation

A) Assist the client in expressing alternative behaviors: This action is more appropriate for later phases of the therapeutic relationship. During the orientation phase, the focus is on establishing rapport and trust rather than implementing behavioral changes.

B) Establish the responsibilities of the nurse and client: Clarifying the roles and responsibilities of both the nurse and the client is a critical task during the orientation phase. This step helps set clear expectations, promotes understanding, and creates a safe environment for the client, which is essential for effective therapeutic engagement.

C) Facilitate the client's problem-solving skills: While enhancing problem-solving skills is important in therapy, it typically occurs in later phases after trust and rapport have been established. The orientation phase is primarily about getting to know the client and their needs.

D) Determine previous coping skills used by the client: Understanding past coping mechanisms is valuable, but this exploration is more suitable for subsequent phases of the relationship. The orientation phase focuses on initial assessments and building a connection, rather than diving into the client's history of coping strategies.

A. "That can't be true. The only voices in this room are yours and mine." B. "Do you recognize the voices as belonging to anyone you know?" C. "I understand the voices are frightening you, but I do not hear any voices." D. "You shouldn't be afraid when you think the voices are telling you to hurt yourself."

Correct Answer is C

Explanation

A. "That can't be true. The only voices in this room are yours and mine.": This response dismisses the client’s experience and can invalidate their feelings, which is not therapeutic or supportive.

B. "Do you recognize the voices as belonging to anyone you know?": While this question could gather more information, it might divert the focus from the client’s immediate feelings of fear and distress.

C. "I understand the voices are frightening you, but I do not hear any voices.": This response validates the client's experience of fear and acknowledges their distress while also gently indicating that the nurse does not perceive the voices. It encourages open communication about the client’s feelings.

D. "You shouldn't be afraid when you think the voices are telling you to hurt yourself.": This response is inappropriate as it minimizes the client’s feelings and does not address the seriousness of their statements about self-harm. It’s crucial to acknowledge their fear rather than dismissing it.

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A nurse is caring for a client who refuses a blood transfusion. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is building a therapeutic relationship with a newly admitted client. Which of the following actions should the nurse plan to take during the orientation phase of the relationship?

Correct Answer is B

Explanation

A nurse observes a client on the psychiatric unit muttering and standing near a window. The client states, "The voices are telling me to jump." Which of the following is an appropriate response by the nurse?

Correct Answer is C

Explanation

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