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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View Related questions
Correct Answer is C
Explanation
Choice A Reason
Lifting the client to the bed with assistance is not recommended during a seizure. Moving the client can increase the risk of injury to both the client and the nurse. The primary focus should be on ensuring the client’s safety by preventing injury from nearby objects and allowing the seizure to run its course.
Choice B Reason
Turning the client onto their back is not advisable during a seizure. This position can increase the risk of airway obstruction and aspiration. Instead, the client should be turned onto their side to maintain an open airway and allow any secretions to drain from the mouth, reducing the risk of aspiration.
Choice C Reason
Clearing the nearby area of furniture is the most appropriate action. This helps to prevent the client from injuring themselves on hard or sharp objects during the seizure. Ensuring a safe environment is a key priority in managing a seizure, as it minimizes the risk of physical harm.
Choice D Reason
Placing a tongue depressor in the client’s mouth is an outdated and dangerous practice. It can cause injury to the client’s teeth, mouth, or airway. There is also a risk of the client biting down and breaking the depressor, leading to choking hazards. Modern seizure management guidelines strongly advise against placing any objects in the client’s mouth during a seizure.
Correct Answer is A
Explanation
Choice A Reason:
Cranial nerve VII, also known as the facial nerve, is responsible for controlling the muscles of facial expression. When assessing this nerve, a nurse would expect to see symmetrical facial movements, such as a symmetrical smile. This indicates that the facial nerve is functioning properly on both sides of the face. Any asymmetry could suggest a problem with the facial nerve, such as Bell’s palsy or a stroke.
Choice B Reason:
The position of the tongue is controlled by cranial nerve XII, the hypoglossal nerve, not cranial nerve VII. The hypoglossal nerve is responsible for the movements of the tongue, and a midline position indicates normal function of this nerve. Therefore, this response is not relevant to the assessment of cranial nerve VII.
Choice C Reason:
Turning the head against resistance is a test for cranial nerve XI, the accessory nerve. This nerve controls the sternocleidomastoid and trapezius muscles, which are involved in head and shoulder movements. Assessing the ability to turn the head against resistance helps evaluate the function of the accessory nerve, not the facial nerve.
Choice D Reason:
Pupillary constriction in response to light is a function of cranial nerve III, the oculomotor nerve. This nerve controls the muscles that constrict the pupil in response to light, a reflex known as the pupillary light reflex. This response is not related to the function of cranial nerve VII.
