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 ["B","C","D"]
Explanation
Choice A Reason:
When providing client education about the medication, the nurse focuses on informing the client about the purpose, dosage, and potential side effects of the medication. This step is crucial for ensuring that the client understands their treatment plan and can adhere to it properly. However, this is not the appropriate time to compare the medication administration record (MAR) against the medication container. The comparison should be done during the actual medication administration process to prevent errors.
Choice B Reason:
At the client’s bedside before administering the medication, the nurse should compare the MAR against the medication container. This step is part of the “three checks” process, which helps ensure that the correct medication is given to the right patient at the right time. By verifying the medication at the bedside, the nurse can catch any discrepancies and prevent potential medication errors.
Choice C Reason:
Before selecting the medication container, the nurse should compare the MAR against the medication container. This is the first of the “three checks” and is essential for ensuring that the correct medication is selected from the storage area. This step helps prevent errors that could occur if the wrong medication is chosen.
Choice D Reason:
While removing medication from the container, the nurse should again compare the MAR against the medication container. This is the second of the “three checks” and serves as an additional safeguard to ensure that the correct medication is being prepared for administration. This step helps catch any errors that might have been missed during the initial selection.
Choice E Reason:
When documenting the medication administration, the nurse records the details of the medication given, including the time, dosage, and any observations. While accurate documentation is crucial for maintaining a complete medical record, this is not the appropriate time to compare the MAR against the medication container. The comparison should be done during the medication administration process to ensure accuracy.
Correct Answer is C
Explanation
Choice A Reason:
Instructing the client to take deep, rhythmic breaths can help in managing pain by promoting relaxation and reducing muscle tension. Deep breathing exercises are a common nonpharmacological intervention for pain relief. However, for localized back pain, this method might not be as effective as applying an ice pack directly to the affected area.
Choice B Reason:
Encouraging the client to apply a heating pad for 2 hours at a time can provide relief by increasing blood flow and relaxing muscles. However, prolonged use of heat can sometimes exacerbate inflammation, especially if the pain is due to an acute injury. Therefore, it is generally recommended to alternate between heat and cold therapy.
Choice C Reason:
Applying an ice pack to the client’s back for 1 hour is effective in reducing inflammation and numbing the pain. Cold therapy is particularly useful in the initial stages of pain management as it helps to constrict blood vessels, reducing swelling and providing immediate pain relief. This method is often recommended for acute pain and injuries.
Choice D Reason:
Removing distractions from the client’s room can create a more restful environment, which may help in overall pain management. However, this action alone is unlikely to provide significant relief for localized back pain. It is more of a supportive measure rather than a primary intervention for pain relief.