A nurse is talking with a client who refuses a blood transfusion for religious reasons. Which of the following responses should the nurse make?
"If I were you, I would contact your spiritual director."
"You have a right to change your mind."
"Making this decision is wrong."
"I'm sure that everything will be all right, regardless of your decision."
The Correct Answer is B
The correct answer is B. "You have a right to change your mind." This response respects the client's autonomy and informs them that they can reconsider their decision if they wish. The other responses are inappropriate and should be avoided. "If I were you, I would contact your spiritual director." implies that the nurse does not support the client's decision and tries to persuade them to change it. "Making this decision is wrong." is judgmental and disrespectful of the client's beliefs and values. "I'm sure that everything will be allright, regardless of your decision." is false reassurance and minimizes the potential consequences of the client's decision.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Neonatal Infant Pain Scale (NIPS): The NIPS is a widely used and validated pain assessment tool specifically designed for newborns, including full-term infants like the 38-week gestation newborn in this case. It evaluates behavioral indicators such as facial expressions, crying, arm and leg movement, and physiological indicators like breathing patterns.
B. FACES pain rating scaleis designed for older children who can self-report pain by selecting a facial expression corresponding to their level of discomfort. It is not suitable for newborns who cannot self-report their pain.
C. Premature Infant Pain Profile (PIPP):The PIPP is specifically designed for preterm infants (less than 37 weeks of gestation) and assesses pain based on behavioral and physiological indicators.
D. Visual Analog Scale (VAS): The VAS requires a client to self-report their pain by indicating a point along a continuum, which is not appropriate for newborns.
Correct Answer is ["A","B","C","F"]
Explanation
The nurse is responsible for educating the client and their partner about advance directives and facilitating their decision-making process. Advance directives are legal documents that allow the client to express their preferences for medical care and treatments at the end of life.
They also enable the client to appoint a health care proxy, who is a person who can make health care decisions for the client if they are unable to do so themselves.
The nurse should provide the client with written information about advance directives, document that the provider discussed do-notresuscitate status with the client, and communicate advance directives status via the medical record and shift report.
The nurse should not instruct the client that an advance directive is a legal document and must be honored by care providers, as this may imply coercion or limit the client's right to change their mind.
The nurse should also not inform the client that an advance directive discontinues further care, as this is inaccurate and may discourage the client from completing one.
The nurse should facilitate a power of attorney for health care document only if the client wishes to designate a health care proxy.
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