A nurse is caring for a client who has given informed consent for electroconvulsive therapy. Just before the procedure, the client tells the nurse she is considering not going forward with the treatment. Which of the following statements by the nurse is appropriate?
- A. Most people who have this procedure feel better following the treatment.
- B. Your doctor wouldn't have ordered this treatment unless it was necessary.â€
- C. It's okay to be nervous before this treatment.
- D. You don't have to go through with the treatment.
Correct Answer: D
Rationale: Rationale: Option D is correct because it respects the client's autonomy and right to make decisions about their treatment. The client has the right to refuse treatment, even after giving initial consent. It is important for the nurse to support the client's decision without coercion.
Summary:
A: Incorrect. This statement does not address the client's current decision to refuse treatment.
B: Incorrect. This statement undermines the client's autonomy by implying they should follow the doctor's orders.
C: Incorrect. While acknowledging the client's feelings is important, it does not address the client's decision to refuse treatment.
D: Correct. Respects the client's autonomy and decision-making.
E, F, G: Not applicable.
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Which of the following information provided by the client indicates improvement? Select all that apply.
- A. The client reports frequent toothaches and lack of dental care
- B. The client makes eye contact and smiles when speaking.
- C. The client's adult child prepares two muss per day for the client.
- D. The client's clothing is clean and appropriate for the weather.
- E. The client has gained 1.11 kg 14 ibL BMI is 18.9
- F. The client receives three baths per week from a home care aide.
Correct Answer: B,C,D,E,F
Rationale: Improvement signs encompass hygiene, nutrition, weight gain, and social interaction.
A nurse is providing discharge teaching about home care of a surgical incision to a client who speaks a different language from the nurse. The nurse is communicating with the client using an interpreter. Which of the following actions should the nurse take?
- A. Speak slowly when talking to the interpreter.
- B. Pause in the middle of sentences
- C. Speak directly to the client
- D. Use gestures to convey meaning
Correct Answer: C
Rationale: The correct answer is C: Speak directly to the client. This is important because even when using an interpreter, the nurse should maintain eye contact and address the client directly to establish trust and ensure the message is accurately conveyed. Speaking slowly (choice A) may be helpful, but it is not as crucial as direct communication. Pausing in the middle of sentences (choice B) could lead to confusion. Using gestures (choice D) may not always accurately convey the intended message. Therefore, speaking directly to the client is the most effective way to ensure clear communication and understanding.
Which of the following findings should the nurse report to the provider?
- A. Pink-tinged coloration on the incisional line
- B. Mild swelling under the sutures near the incisional line
- C. Crusting of exudate on the incisional line
- D. Partial separation of the upper part of the incisional line
Correct Answer: D
Rationale: Partial wound separation indicates potential complications needing attention.
The nurse notes that sediment is present in the urine.
- A. Which of the following actions should the nurse take to obtain a sterile urine specimen?
- B. Disconnect the catheter from the collection tubing.
- C. Obtain the specimen from the retention port.
- D. Use the balloon port to obtain the sterile specimen.
- E. Unclamp the collection port below the bag
Correct Answer: B
Rationale: Retention ports allow sterile specimen collection.
A quality control nurse is reviewing medication prescriptions for a group of clients. Which of the following medication prescriptions should the nurse identify as being complete?
- A. Tetracycline 200 mg PO
- B. Epoetin alfa 150 units/kg three times weekly
- C. Digoxin 0.25 mg PD dally
- D. Cimetidine PO twice daily
Correct Answer: C
Rationale: The correct answer is C: Digoxin 0.25 mg PO daily. The rationale for this choice being complete is that it includes the medication name (Digoxin), dose (0.25 mg), route of administration (PO - by mouth), and frequency (daily). This prescription is clear and specific, providing all necessary information for the nurse to accurately administer the medication.
Other choices are incorrect:
A: Missing frequency information.
B: Missing route of administration and frequency.
D: Missing dose and frequency.