A nurse is planning care for a group of clients. The nurse should expect to witness an informed consent for a client who will undergo which of the following procedures?

Administration of an enema.

Performance of a paracentesis.

Insertion of an indwelling urinary catheter.

Placement of an NG tube.

Answer and Explanation

The Correct Answer is B

The correct answer is choice B: Performance of a paracentesis.

Choice A rationale:

Administration of an enema does not require informed consent in the same way that invasive procedures do. Enemas are typically considered routine nursing interventions and are not as invasive as the other options.

Choice B rationale:

This is the correct choice. A paracentesis is an invasive procedure that involves puncturing the abdominal cavity to withdraw fluid. Informed consent is required for procedures that carry potential risks, and paracentesis falls into this category due to the risk of complications such as infection, bleeding, or organ injury.

Choice C rationale:

Insertion of an indwelling urinary catheter is a common nursing procedure that, while invasive, does not typically require informed consent. However, the nurse should still explain the procedure to the client and obtain verbal consent, but it's not the same level of formal informed consent required for more invasive procedures.

Choice D rationale:

Placement of an NG tube, although uncomfortable, is not as invasive as a paracentesis. In most cases, NG tube placement is considered a medical or nursing intervention rather than a procedure that necessitates formal informed consent.

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Correct Answer is C

Explanation

The correct answer is choice C: "I should remove constrictive clothing prior to measuring my blood pressure."

Choice A rationale:

"I will wait 15 minutes after drinking coffee to measure my blood pressure." Caffeine intake can temporarily elevate blood pressure, so waiting 15 minutes after drinking coffee is a good practice. However, this is not the most relevant instruction to ensure accurate blood pressure measurement.

Choice B rationale:

"I will measure my blood pressure while my arm is elevated above my heart." Measuring blood pressure with the arm elevated above the heart can result in artificially low readings. The arm should be supported at heart level for accurate results. Therefore, this statement is incorrect.

Choice C rationale:

"I should remove constrictive clothing prior to measuring my blood pressure." This is the correct choice. Constrictive clothing can impact blood flow and give inaccurate readings. Removing tight clothing ensures the blood pressure cuff can be appropriately placed and that the measurements are reliable.

Choice D rationale:

"I should measure my blood pressure immediately after eating breakfast." Blood pressure can be affected by food intake, so it's recommended to wait at least 30 minutes after eating before measuring blood pressure. This choice is not accurate as immediate post-breakfast measurements may not provide accurate results.

A. Complicated grief. B. Maturational loss. C. Disenfranchised grief. D. Actual loss.

Correct Answer is D

Explanation

The correct answer is choice d. Actual loss.

Choice A rationale: Complicated grief refers to an intense and prolonged period of mourning that interferes with daily life. It is not typically associated with the immediate postoperative period following a mastectomy.

Choice B rationale: Maturational loss is related to the normal life transitions and developmental changes, such as children leaving home or retirement. It does not apply to the loss experienced after a mastectomy.

Choice C rationale: Disenfranchised grief occurs when a person’s grief is not socially recognized or supported, such as the loss of a pet or an ex-spouse. While the grief after a mastectomy can be profound, it is generally acknowledged and supported by healthcare providers and society.

Choice D rationale: Actual loss refers to the tangible loss of a person, object, or body part. In this case, the client is experiencing the loss of a breast, which is a significant and visible change to their body. This type of loss can deeply affect a person’s self-image and emotional well-being.

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A nurse is planning care for a group of clients. The nurse should expect to witness an informed consent for a client who will undergo which of the following procedures?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure their blood pressure daily. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is caring for a client who is postoperative following a mastectomy. The client states, "I can barely look at myself in the mirror." The nurse should identify that the client is experiencing which of the following?

Correct Answer is D

Explanation

A nurse is documenting client care in a client's electronic health record. Which of the following entries should the nurse include in the documentation?

A nurse is assisting with the admission of an older adult client to an acute care facility. The client states that they are afraid to go to sleep, fearing they will not wake up. Which of the following is a therapeutic response the nurse should make?

A nurse is providing care to four clients in an acute care setting. The nurse should identify that which of the following client statements presents an ethical dilemma?

A nurse is contributing to the plan of care for a client who practices Islam. Which of the following questions should the nurse ask the client to clarify the client's religious preferences?

A nurse is reinforcing teaching with a client about self-administration of ophthalmic drops. Which of the following instructions should the nurse include?

A nurse is preparing to document information about a client's lower legs, which are swollen with 6 mm edema. Which of the following information should the nurse document?

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A nurse is caring for a client who has a new diagnosis of cancer. Which of the following actions by the nurse maintains the client's confidentiality?