A nurse is instructing a school-age child who has asthma about the use of a peak expiratory flow meter.

Which of the following instructions should the nurse include in the teaching?

Choice A reason:

Explaining the procedure to the client before verifying informed consent is not an appropriate action: While it is essential to explain the procedure to the client and ensure they have a clear understanding of what they are consenting to, this step typically occurs before the informed consent form is presented. The purpose of the informed consent form is to document that the client has received adequate information and has given their consent voluntarily

Choice B reason:

Confirming the client's signature is authentic is the correct action. Verifying the record of informed consent for a client scheduled for surgery involves several important steps. Of these, the nurse's primary responsibility is to ensure that the client's signature on the informed consent form is authentic. This means ensuring that the client themselves or their authorized representative has signed the form willingly and without coercion.

Choice C reason:

Providing information on the informed consent form about the benefits of the surgery is not an appropriate action: The informed consent form typically contains information about the procedure, its risks, possible complications, and alternatives, but it is not the nurse's responsibility to provide this information. The healthcare provider or surgeon is responsible for explaining the details of the surgery to the client before obtaining their consent.

Choice D reason:

Informing the client about the condition that requires treatment is not an appropriate action: The responsibility of informing the client about their medical condition, the need for treatment, and the available options lies with the healthcare provider or surgeon, not the nurse. The nurse may assist in providing information or answering questions, but the primary responsibility for discussing the medical condition lies with the provider.

The correct answer is c. Document the client's behavior prior to being placed in seclusion.

Rationale for Choice a. Discuss with the client his inappropriate behavior prior to seclusion:

While discussing the client's behavior may be helpful in some situations, it is not the most appropriate action to take immediately before seclusion. This is because:

1. Escalation:Attempting to discuss behavior in the moments leading up to seclusion can potentially escalate the situation and further jeopardize the safety of the client,staff,and other patients.
2. Impaired Insight:Clients requiring seclusion may have limited ability to engage in rational discussion due to heightened emotional states,cognitive impairment,or acute mental illness.
3. Limited Receptiveness:The client may not be receptive to feedback or discussion while in a state of crisis,potentially leading to frustration and further agitation.

Rationale for Choice b. Offer fluids every 2 hr.:

Offering fluids is a basic nursing intervention, but it is not the priority action in this scenario. The primary focus at this time is ensuring safety and managing the acute behavioral crisis. Addressing hydration needs can be attended to after the client is safely placed in seclusion.

Rationale for Choice d. Assess the client’s behavior once every hour.:

Regular assessment is crucial, but hourly assessment is not frequent enough in this situation. Clients in seclusion require close monitoring and assessment at more frequent intervals to ensure their safety and well-being, as well as to evaluate the effectiveness of the seclusion intervention.

Rationale for Choice c. Document the client’s behavior prior to being placed in seclusion.:

This is the most appropriate action for the nurse to take for the following reasons:

1. Legal and Ethical Requirements:Accurate documentation of the client's behavior prior to seclusion is essential for legal and ethical reasons.It serves as a record of the rationale for seclusion,supporting the decision-making process and ensuring adherence to best practices and patient rights.
2. Assessment and Intervention Planning:Detailed documentation provides valuable information for ongoing assessment and intervention planning.It allows healthcare professionals to track the client's progress,identify patterns in behavior,and make informed decisions about the continuation or discontinuation of seclusion.
3. Communication and Collaboration:Comprehensive documentation facilitates effective communication and collaboration among the healthcare team members,ensuring continuity of care and promoting a holistic approach to the client's treatment.
4. Evaluation and Quality Improvement:Accurate documentation enables evaluation of the effectiveness of seclusion interventions and contributes to quality improvement initiatives within the healthcare setting.