A nurse is speaking with the partner of a client who speaks a different language than the nurse. The partner tells the nurse that the client does not want to sign an informed consent for an urgent cesarean birth. Which of the following actions should the nurse take?
Ask the client's partner to sign as next of kin.
Document the client's refusal in their medical record.
Check to see if the client has an advance directive.
Ask the provider to explain the procedure through an interpreter.
The Correct Answer is D
Rationale:
A. Ask the client's partner to sign as next of kin: The partner cannot legally provide informed consent on behalf of the client unless they have legal power of attorney. Consent must come from the client unless they are incapacitated.
B. Document the client's refusal in their medical record: While documentation is important, it should only occur after ensuring the client fully understands the procedure. Without effective communication, refusal may not be informed.
C. Check to see if the client has an advance directive: Advance directives guide care if the client is incapacitated but may not apply if the client is alert and able to make decisions about the current procedure.
D. Ask the provider to explain the procedure through an interpreter: Using a professional interpreter ensures clear communication so the client can make an informed decision about the cesarean birth, respecting autonomy and reducing misunderstanding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. “I should try to focus on pleasant images to help replace stressful and negative feelings I have.”: This describes guided imagery, a relaxation technique that uses visualization to reduce stress. While helpful, it does not involve the cognitive restructuring.
B. “I will use my smartwatch to monitor my sleep and heart rate to assist me with gaining voluntary control over my stress.”: This reflects biofeedback, where physiological responses are tracked and managed through conscious control. It involves physical awareness, not cognitive reinterpretation of stress.
C. "I should reassess the situation and change my perceptions of stress by replacing irrational beliefs.”: This is cognitive reframing, a technique that helps clients identify and challenge distorted thinking and replace it with more rational, constructive thoughts to alter their emotional responses to stress.
D. "I will tense my muscles for 8 seconds and then relax them to release the tension caused by my stress.”: This refers to progressive muscle relaxation, which targets physical symptoms of stress rather than the cognitive processes addressed in cognitive reframing.
Correct Answer is C
Explanation
Rationale:
A. Leakage of IV fluid: Leakage of IV fluid at the insertion site suggests infiltration, not phlebitis. In infiltration, fluid escapes into surrounding tissues, leading to swelling and coolness, but not inflammation of the vein itself.
B. Blood leakage: Blood leakage is usually related to poor catheter stabilization or improper insertion, not phlebitis. It does not indicate inflammation or irritation of the vein wall, which are hallmark signs of phlebitis.
C. Red streak: A red streak following the path of the vein is a classic sign of phlebitis. It indicates inflammation of the vein wall and is often accompanied by pain, warmth, and swelling along the vein.
D. Purulent drainage: Purulent drainage is a sign of infection rather than phlebitis. While phlebitis can lead to infection if untreated, purulent drainage points to a more serious complication involving bacterial growth.
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