A nurse is reinforcing teaching with a newly licensed nurse about informed consent. Which of the following statements should the nurse make?

"The client can revoke consent even after the procedure has begun."

"The nurse is responsible for obtaining informed consent.”

"Consent must be obtained from a family member if a client has a mental illness."

"The charge nurse will explain the risks of the procedure to the client.”

Answer and Explanation

The Correct Answer is A

Rationale:

A. "The client can revoke consent even after the procedure has begun.": Clients have the legal right to withdraw consent at any time, including during a procedure. Respecting this autonomy is essential, and healthcare providers must stop the procedure if the client revokes consent.

B. "The nurse is responsible for obtaining informed consent.": Obtaining informed consent is the responsibility of the provider performing the procedure, who must ensure the client understands the risks, benefits, and alternatives. Nurses typically witness and verify the signature but do not obtain consent.

C. "Consent must be obtained from a family member if a client has a mental illness.": Consent depends on the client’s decision-making capacity, not solely on the presence of mental illness. If the client is competent, they can provide consent; if not, a legally authorized representative may be involved.

D. "The charge nurse will explain the risks of the procedure to the client.": Explaining procedure risks is the responsibility of the healthcare provider performing the procedure, not the charge nurse. This ensures that the explanation is accurate and comprehensive.

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Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

Rationale:

• Administer aspirin for fever: Aspirin can increase circulating thyroid hormones by displacing T4 and T3 from protein-binding sites. In a hyperthyroid or recently post-thyroidectomy patient, this may precipitate or worsen a thyroid storm. Acetaminophen is a safer antipyretic choice.

• Apply cooling blanket: The client’s postoperative fever (38.3°C), elevated heart rate (98/min), and history of hyperthyroidism indicate a risk for thyroid storm. External cooling is a supportive measure to manage hyperthermia during this critical period.

• Monitor vital signs every 4 hours: This is anticipated to detect signs of complications such as thyroid storm, hemorrhage, or airway compromise. Postoperative clients require close observation to identify early changes in temperature, pulse, or respiration.

• Place client on telemetry: Cardiac monitoring is essential after thyroidectomy in clients with a history of hyperthyroidism. Increased metabolic demand, fever, and potential for arrhythmias justify continuous cardiac observation.

• Palpate thyroid area to assess for hematoma: A neck hematoma is a potentially life-threatening complication of thyroid surgery. It can lead to airway obstruction. Palpation and inspection for swelling or firmness around the incision site are critical nursing assessments.

A. "We've seen steady improvement in other clients who are depressed." B. "Tell me what you know about depression," C. "No one really knows the answer to that question." D. "The important thing is that he gets better, not how long it takes."

Correct Answer is B

Explanation

Rationale:

A. "We've seen steady improvement in other clients who are depressed.": While this may sound reassuring, it provides generalized information that may create unrealistic expectations. It does not address the partner’s specific concerns or open up a dialogue for emotional support or understanding.

B. "Tell me what you know about depression,": This response encourages open communication and assesses the partner's understanding of the condition. It allows the nurse to provide accurate, individualized information and emotional support based on what the partner already knows or believes.

C. "No one really knows the answer to that question.": Though factually true, this statement may seem dismissive or lacking empathy. It does not invite discussion or support the emotional needs of the partner, who is likely feeling uncertain or overwhelmed.

D. "The important thing is that he gets better, not how long it takes.": This response minimizes the partner’s valid concern about recovery time. It may come across as invalidating and does not provide helpful or therapeutic communication.

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A nurse is reinforcing teaching with a newly licensed nurse about informed consent. Which of the following statements should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse has reviewed the Vital Signs at 1000. Exhibits For each potential provider prescription, click to specify if the prescription is anticipated or non-anticipated for the client.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

A nurse is caring for a client who was recently diagnosed with depression. The client's partner asks when he will get better. Which of the following is an appropriate response by the nurse?

Correct Answer is B

Explanation

A nurse is assisting with the care of a client who is in active labor. Exhibits The nurse is assisting with the care of the client following the insertion of an epidural. For each nursing intervention, click to specify if the intervention is essential or contraindicated for the client.

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