A nurse is caring for a newly admitted client who has bacterial meningitis. Which of the following actions should the nurse take?

Choice A reason: Informing the client that consent cannot be withdrawn is incorrect, as clients can revoke consent at any time before or during the procedure. This misrepresents patient rights, making it an unethical and illegal statement for the nurse’s role.
Choice B reason: Identifying risks or discomforts is the surgeon’s responsibility, not the nurse’s, during consent. The nurse verifies understanding and voluntariness, not provides risk details, so this action is outside the nurse’s scope, making it incorrect.
Choice C reason: Ensuring the client understands the procedure and voluntarily agrees is the nurse’s role when witnessing consent. This verifies informed, autonomous decision-making, aligning with legal and ethical standards, making it the correct responsibility for the nurse.
Choice D reason: Providing a detailed surgical technique explanation is the surgeon’s role, not the nurse’s. The nurse ensures comprehension and consent, not technical details, so this action exceeds the nurse’s scope during consent, making it incorrect.

Choice A reason: Experiencing delusions can contribute to agitation, but it is not the strongest predictor of violence. Delusions may lead to unpredictable behavior, but past actions are more reliable indicators, so this factor is less definitive, making it incorrect.
Choice B reason: A history of being in prison indicates past legal issues but not necessarily violent behavior. Incarceration alone is not a direct predictor of future violence, so this factor is less reliable than actual violent history, making it incorrect.
Choice C reason: A history of violent behavior is the best predictor of future violence, as past actions strongly correlate with recurrence, per evidence-based risk assessments. This reliable indicator guides safety planning, making it the correct factor to emphasize in teaching.
Choice D reason: Substance use disorder increases impulsivity and aggression risk, but it is less predictive than a documented history of violence. Substance use is a contributing factor, not the strongest indicator, so this is incorrect compared to past behavior.