The nurse is assessing an adult client when suddenly the client refuses to continue the examination. What is the nurse's next step?
1. Give the client a short break and then resume the assessment.
2. Document what was done and what was refused.
3. Summon another nurse to the room to serve as a witness.
4. Enlist the assistance of the client's family to encourage the rest of the assessment.
2
Rationale 1: The nurse must never attempt to influence or coerce the client to agree to a procedure; giving the client a break and then resuming the assessment could be viewed as a form of coercion.
Rationale 2: The client has the right to refuse care. It is important to document what has been done and what, if anything, has been refused.
Rationale 3: It is not necessary for another nurse to witness a client's refusal of care. The nurse should document what was done and what the client refused.
Rationale 4: Allowing a family member to be present during the assessment may be helpful, but the client's wishes (refusal) must be respected.
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