The nurse is caring for a client who has just refused to undergo an invasive procedure that could possibly extend his life by a few months. The nurse supports the client's decision based on which essential value?
a. Equality
b. Truth
c. Human dignity
d. Autonomy
ANS: D
Advocacy should support client autonomy. Clients need to be in control of their own destiny, even when the decision reached is not what you as the nurse would recommend for the client's health and well-being.
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A man with a neurogenic bladder secondary to a spinal tumor has been taking bethanechol. The patient has illuminated his call light, and the nurse has found him anxious, diaphoretic, and visibly flushed
Following a safety assessment, what action should the nurse take? A) Prepare to administer an IV dose of epinephrine to mitigate the effects of acetylcholine. B) Contact the physician as the patient may be experiencing a cholinergic crisis. C) Insert a Foley catheter as the patient may have excessive urine in his bladder. D) Assess the volume of the patient's bladder contents using a bladder ultrasound.
A nurse is caring for a 12-year-old girl with a severe peanut allergy. The girl's parents are upset because the school does not permit her to carry her EpiPen® with her; it must remain in the school's office as per school regulations
How should the nurse respond? A) "She is allowed by law to carry her EpiPen® with her; I will talk to school authorities." B) "Let's file an action plan and keep it in the school office in the event of anaphylaxis." C) "Make sure she wears a medical alert bracelet so that school staff know she has allergies." D) "I will be happy to train school authorities and staff to recognize anaphylaxis."
A client is demonstrating yellow pigmentation of the skin and sclera. Which of the following can be used to describe this client's symptoms? (Select all that apply.)
1. Jaundice 2. Dyspepsia 3. Icterus 4. Sclerosis 5. Kernicterus 6. Cirrhosis
Which action will the nurse take to reduce the risk of excoriation to the mucosal lining of the patient's nose from a nasogastric tube?
a. Instill Xylocaine into the nares once a shift. b. Tape tube securely with light pressure on nare. c. Lubricate the nares with water-soluble lubricant. d. Apply a small ice bag to the nose for 5 minutes every 4 hours.