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 ["B","C","E"]
Explanation
Choice A Reason:
A negative Chvostek’s sign is not expected in a client with hypocalcemia. The Chvostek’s sign is a clinical indicator of hypocalcemia, where tapping the facial nerve triggers facial muscle twitching. A positive Chvostek’s sign indicates neuromuscular irritability due to low calcium levels. Therefore, a negative Chvostek’s sign would not be consistent with hypocalcemia.
Choice B Reason:
A positive Trousseau’s sign is a classic indicator of hypocalcemia. This sign is elicited by inflating a blood pressure cuff on the upper arm to a level above the systolic pressure for several minutes. The resultant carpopedal spasm (involuntary contraction of the hand and wrist muscles) is a positive Trousseau’s sign, indicating neuromuscular irritability due to low calcium levels.
Choice C Reason:
Muscle cramps are a common syptom of hypocalcemia. Low calcium levels increase neuromuscular excitability, leading to involuntary muscle contractions and cramps. These cramps can occur in various muscle groups, often causing significant discomfort.
Choice D Reason:
Abdominal distention is not typically associated with hypocalcemia. While abdominal distention can result from various gastrointestinal issues, it is not a direct symptom of low calcium levels. Hypocalcemia primarily affects neuromuscular function rather than causing abdominal distention.
Choice E Reason:
Tingling sensation around the lips, also known as perioral tingling, is a common symptom of hypocalcemia. This occurs due to increased neuromuscular irritability caused by low calcium levels, leading to sensations of tingling or numbness around the mouth.
Correct Answer is A
Explanation
Choice A Reason:
Airborne precautions are necessary for clients with tuberculosis (TB) because TB is an airborne disease. It is transmitted through tiny droplets released into the air when an infected person coughs, sneezes, or talks. These precautions include placing the client in a negative pressure room, using N95 respirators for healthcare workers, and ensuring the client wears a surgical mask when outside their room. These measures help prevent the spread of TB to others.
Choice B Reason:
Protective precautions, also known as reverse isolation, are used to protect immunocompromised patients from infections. These precautions are not appropriate for a client with TB, as the primary concern is preventing the spread of TB from the infected client to others, not protecting the client from external infections.
Choice C Reason:
Contact precautions are used for infections that are spread by direct or indirect contact with the patient or their environment, such as MRSA or C. difficile. TB is not spread through contact but through airborne particles, so contact precautions are not sufficient for preventing the transmission of TB.
Choice D Reason:
Droplet precautions are used for diseases that are spread through large respiratory droplets, such as influenza or pertussis. While TB is a respiratory disease, it is spread through much smaller airborne particles that can remain suspended in the air for longer periods, making airborne precautions necessary instead of droplet precautions.
