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 D
Explanation
Choice A Reason:
Leaving a transfer belt in place until the client returns from radiology is not recommended. The transfer belt is used to assist in moving the client safely, but it should be removed once the client is securely seated in the wheelchair to prevent discomfort or potential injury.
Choice B Reason:
Positioning the client so their weight is shifted forward is not a standard practice for transferring a client to a wheelchair. Proper positioning involves ensuring the client is seated comfortably and securely, with their weight evenly distributed to prevent falls or injuries.
Choice C Reason:
Lowering the footplates before transferring the client from the bed is incorrect. The footplates should be raised to allow the client to safely transfer from the bed to the wheelchair without tripping or getting their feet caught.
Choice D Reason:
Backing the wheelchair into the elevator is the correct action. This ensures that the client enters the elevator facing forward, which is safer and more comfortable for the client. It also allows the nurse to maintain better control of the wheelchair during the transition.
Correct Answer is C
Explanation
Choice A: Have a padded tongue blade available at the client’s bedside.
Having a padded tongue blade available is not recommended for seizure management. Inserting any object into a patient’s mouth during a seizure can cause injury to the teeth, gums, or jaw1. Current guidelines advise against placing anything in the mouth of a person having a seizure. Instead, focus on ensuring the patient’s safety by turning them on their side to maintain an open airway and prevent aspiration.
Choice B: Keep the four side rails down when the client is in bed.
Keeping the side rails down is not advisable for a client with a seizure disorder. To prevent injury during a seizure, it is important to keep the side rails up and padded. This helps prevent the client from falling out of bed and sustaining injuries. Additionally, the bed should be kept in its lowest position to minimize the risk of injury from falls.
Choice C: Keep suction equipment available in the client’s room.
Keeping suction equipment available is crucial for managing a client with a seizure disorder. During a seizure, there is a risk of aspiration due to excessive salivation or vomiting. Having suction equipment readily available allows the nurse to quickly clear the client’s airway, reducing the risk of aspiration and ensuring the client can breathe properly.
Choice D: Have wire cutters available at the client’s bedside.
Wire cutters are not typically necessary for managing a seizure disorder. They are sometimes mentioned in the context of clients with Vagus Nerve Stimulators (VNS), where the wire cutters might be used in an emergency to cut the VNS wire. However, this is a rare situation and not a standard precaution for all clients with seizure disorders4.