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
Explanation
Choice A Reason:
Dissociation is a defense mechanism where a person disconnects from their thoughts, feelings, or sense of identity. It often occurs in response to trauma or extreme stress, allowing the individual to distance themselves from the reality of the situation. In this case, the client is not showing signs of dissociation, such as feeling detached from reality or experiencing memory gaps. Instead, they are avoiding the reality of their partner’s condition.
Choice B Reason:
Denial is a defense mechanism where a person refuses to accept the reality of a situation to avoid dealing with painful emotions. The client’s statement about planning a trip despite their partner’s terminal condition indicates that they are not acknowledging the severity of the situation. This refusal to accept reality helps them cope with the emotional distress associated with their partner’s impending death.
Choice C Reason:
Regression involves reverting to behaviors from an earlier stage of development when faced with stress. This might include actions like thumb-sucking, bed-wetting, or other childlike behaviors. The client’s statement does not indicate a return to earlier developmental behaviors but rather a refusal to accept the current reality.
Choice D Reason:
Displacement is a defense mechanism where negative emotions are redirected from their original source to a less threatening target. For example, someone might take out their frustration with their boss on a family member. In this scenario, the client is not redirecting their emotions but rather avoiding the reality of their partner’s condition.
Correct Answer is B
Explanation
Choice A reason:
Attaching the restraints using a quick-release tie is essential for ensuring the safety of the client and the healthcare staff. A quick-release tie allows for the rapid removal of the restraints in case of an emergency, such as a fire or a sudden change in the client’s condition. This method is recommended by healthcare guidelines to ensure that restraints can be removed swiftly and safely.
Choice B reason:
Contacting the provider for a PRN (as needed) prescription for restraints is a necessary step to ensure that the use of restraints is authorized and documented. Restraints should only be used when absolutely necessary and with proper authorization to prevent misuse and to protect the client’s rights. This step ensures that the decision to use restraints is made with careful consideration and in accordance with legal and ethical standards.
Choice C reason:
Securing the restraints to a side rail on the client’s bed is not recommended. This practice can pose a significant risk to the client, as it can lead to injury if the client attempts to move or if the side rail is raised or lowered. Restraints should be secured to a part of the bed frame that does not move, such as the bed frame itself, to ensure the client’s safety.
Choice D reason:
Leaving enough room to fit three fingers between the restraints and the client’s wrist is incorrect. The correct practice is to leave enough room to fit two fingers between the restraints and the client’s wrist. This ensures that the restraints are not too tight, which could cause circulation problems or skin damage, and not too loose, which could allow the client to remove them.