A staff nurse is teaching a newly hired nurse how to complete an informed consent document for a client. The staff nurse should include that the nurse’s signature on the form confirms which of the following requirements? (Select all that apply.)
The client speaks the same language as the nurse.
The client signed in the nurse’s presence.
The client was not coerced.
The client has legal authority to do so.
The client does not have a mental health condition.
Correct Answer : B,C,D
Choice A Reason:
The requirement that the client speaks the same language as the nurse is not a standard criterion for informed consent. While effective communication is crucial, the presence of an interpreter can facilitate understanding if there is a language barrier. The nurse’s signature does not confirm the language spoken by the client.
Choice B Reason:
The nurse’s signature on the informed consent form confirms that the client signed the document in the nurse’s presence. This is a standard practice to ensure that the consent was given voluntarily and that the client was present at the time of signing. It helps in verifying the authenticity of the consent.
Choice C Reason:
The nurse’s signature also confirms that the client was not coerced into signing the consent form. Informed consent must be given voluntarily, without any form of pressure or coercion. This ensures that the client’s decision is made freely and with full understanding of the procedure or treatment.
Choice D Reason:
The nurse’s signature confirms that the client has the legal authority to give consent. This means that the client is of legal age and has the mental capacity to understand the information provided and make an informed decision. It is essential to ensure that the client is legally competent to consent to the treatment or procedure.
Choice E Reason:
The requirement that the client does not have a mental health condition is not a standard criterion for informed consent. Clients with mental health conditions can still provide informed consent if they have the capacity to understand the information and make a decision. The nurse’s signature does not confirm the mental health status of the client.
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Correct Answer is C
Explanation
Choice A Reason
Increased heart rate during physical activity can be a common finding in clients who have been on bed rest for an extended period. This is due to deconditioning of the cardiovascular system. While it is important to monitor and address, it is not the most immediate concern compared to other potential complications.
Choice B Reason
Loss of appetite is another common issue in clients who have been on prolonged bed rest. It can lead to nutritional deficiencies and weight loss, which are significant concerns. However, it is not as urgent as other findings that might indicate more acute complications.
Choice C Reason
Left lower extremity tenderness is the most critical finding and should be identified as the priority. This symptom can indicate deep vein thrombosis (DVT), a serious condition that can lead to life-threatening complications such as pulmonary embolism if not promptly addressed. DVT is a common risk for clients who have been immobile for extended periods, making it a top priority for immediate
intervention.
Choice D Reason
Musculoskeletal weakness is expected in clients who have been on bed rest for several weeks. It results from muscle atrophy and deconditioning. While it is an important issue to address through rehabilitation and physical therapy, it does not pose an immediate threat to the client’s life compared to the risk of DVT.
Correct Answer is B
Explanation
Choice A: Seat the client in a chair for 30 minutes prior to applying the stockings.
Seating the client in a chair for 30 minutes before applying the stockings is not necessary. In fact, it is recommended to apply antiembolic stockings while the client is in a supine position to prevent blood from pooling in the legs. This ensures that the stockings fit properly and provide the intended compression to promote venous return.
Choice B: Measure the length of the client’s leg from the heel to the gluteal fold.
Measuring the length of the client’s leg from the heel to the gluteal fold is essential for ensuring the correct fit of knee-length antiembolic stockings. Proper measurement helps in selecting the right size, which is crucial for the stockings to be effective in preventing deep vein thrombosis (DVT) by promoting blood circulation. Incorrectly sized stockings may either be too tight, causing discomfort and impaired circulation, or too loose, failing to provide adequate compression.
Choice C: Instruct the client to point their toes while applying the stockings.
Instructing the client to point their toes while applying the stockings is not a standard practice. Instead, the nurse should gather the stocking material and gently roll it over the foot and up the leg, ensuring it is evenly distributed and free of wrinkles. This method helps in applying the stockings smoothly and effectively without causing discomfort or improper fit.
Choice D: Roll the top of the client’s stockings down to just below the knee.
Rolling the top of the stockings down to just below the knee is incorrect and can lead to a tourniquet effect, which can impede blood flow and increase the risk of DVT. The stockings should be applied smoothly and should extend to their full length without being rolled down to ensure proper compression and effectiveness.