A nurse is obtaining informed consent from a client who is scheduled for an invasive procedure. The client states, "I don't understand why this procedure is necessary." Which of the following actions should the nurse take?
Ask the client to sign the consent form anyway.
Notify the charge nurse about the situation.
Remind the client about the specifics of the procedure.
Explain to the client that the procedure will help treat his diagnosis
The Correct Answer is B
The correct answer is B. Notify the charge nurse about the situation. Informed consent is when a healthcare provider explains a medical treatment to a patient before the patient agrees to it. The patient has the right to know their state of health, the diagnosis, and the treatments available, and to choose any alternative. The nurse is responsible for obtaining consent when initiating care, and reviewing consent before providing the care ordered by another health care professional. If the patient does not understand why the procedure is necessary, the nurse should notify the charge nurse or the physician who ordered the procedure, so that they can provide more information and answer any questions.
The nurse should not ask the client to sign the consent form anyway (A), as this would violate the patient's right to autonomy and self-determination.
The nurse should not remind the client about the specifics of the procedure (C) or explain to the client that the procedure will help treat his diagnosis (D), as these are not within the nurse's scope of practice and may be considered as giving medical advice.
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Correct Answer is D
Explanation
The correct answer is choice D. Document the client’s condition after every 15 minutes.
Choice A rationale:
Requesting a PRN restraint prescription for clients who are aggressive is not appropriate because restraints should only be used as a last resort and not on a PRN basis. Restraints should be used only when necessary to ensure the safety of the patient and others, and always with a specific, time-limited order.
Choice B rationale:
Removing the client’s restraint every 4 hours is not frequent enough. Restraints should be removed more frequently to assess the patient’s condition, provide care, and ensure that the restraint is still necessary.
Choice C rationale:
Attaching the restraint to the bed’s side rails is unsafe. Restraints should be attached to a part of the bed frame that moves with the patient to prevent injury.
Choice D rationale:
Documenting the client’s condition every 15 minutes is the correct guideline. Frequent documentation ensures that the patient’s condition is continuously monitored, and any changes can be addressed promptly to ensure safety and well-being.
Correct Answer is B
Explanation
Answer: B. Client isolates themselves from their family and friends
Rationale: A crisis is a situation that overwhelms a person's usual coping mechanisms and causes psychological distress. A client who isolates themselves from their family and friends is showing a sign of impaired social functioning, which indicates a crisis. The other options are not specific to a crisis and could be manifestations of anxiety or depression.
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