A physician orders a nasogastric (NG) tube for a young adult diagnosed with end-stage ovarian cancer and suspected of having a bowel obstruction. The newly hired nurse explains the procedure and rationale for NG tube placement. The client refuses to consent to NG tube placement, stating, "I would rather keep vomiting than have the tube in my nose." Following the American Nurses Association Code of Ethics for Nurses, what should the nurse do next?
Delegate the NG tube placement to a more experienced nurse.
Make a referral to Social Services related to body image disturbance.
Seek the client's spouse for consent to the procedure.
Document the client's wishes and notify the physician.
The Correct Answer is D
Choice A reason : Delegating the NG tube placement to a more experienced nurse does not address the client's refusal of the procedure. The nurse must respect the client's autonomy and decision-making rights.
Choice B reason : While a referral to Social Services may be appropriate in some cases, it does not directly address the immediate concern of the client's refusal of the NG tube placement.
Choice C reason : Seeking consent from the client's spouse is not appropriate as the client is competent and has the right to refuse treatment. The client's autonomy must be respected.
Choice D reason : Documenting the client's wishes and notifying the physician is the correct action. The nurse must respect the client's right to refuse treatment and communicate this decision to the physician so that alternative management can be considered.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason : The immediate safety of the client is the nurse's primary concern. Assessing the risk for immediate harm is crucial to prevent further abuse and to ensure the client's well-being. This involves evaluating the severity of the situation and the potential for future harm¹.
Choice B reason : While referring the client to a community support group is important for long-term support, it is not the immediate priority when a client reports abuse.
Choice C reason : Implementing a safety plan is a critical step, but it follows the initial assessment of immediate risk. The safety plan will be part of the ongoing support and intervention for the client.
Choice D reason : Instructing the client on how to leave the relationship is an important aspect of empowering the client; however, it is not the first action to take before assessing immediate risk and ensuring the client's safety.
Correct Answer is B
Explanation
Choice A reason: Encouraging interaction with others by having the client share a room might be overwhelming for a client experiencing hypomanic episodes. Hypomania can involve irritability and impulsivity, making shared spaces potentially stressful. It's important to balance social interaction with the need for a controlled environment¹.
Choice B reason: Providing a calm atmosphere by placing the client in a private room can be beneficial for someone experiencing hypomanic episodes. A private room can reduce overstimulation and help manage symptoms like restlessness, agitation, and sleep disturbances. It allows the client to have a quiet space to retreat to, which can be crucial in managing mood swings¹².
Choice C reason: While a cheerful environment may seem beneficial, having bright drapes in the client's room could potentially contribute to overstimulation. Clients with hypomania are often sensitive to environmental stimuli, so it's important to keep the setting subdued to avoid exacerbating symptoms¹.
Choice D reason: Promoting access to activities by assigning the client to a room near the dayroom can be a double-edged sword. While it facilitates engagement in structured activities, which can be therapeutic, it also increases the risk of overstimulation due to the proximity to a potentially busy and noisy area. Careful consideration of the client's current state is necessary when making this decision¹.
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