The nurse is providing care to a client diagnosed with dementia. What option is an example of the appropriate use of implied consent by the nurse?
a. Preparing to draw blood from a client's arm after asking, "Can I see your arm?"
b. Changing the client's dressing when the client asks, "Will you change this bandage now?"
c. Using the client's monthly allowance to buy a watch when he continuously asks for the time.
d. Arranging for a benign mole to be removed after the client states, "I don't like this here."
ANS: B
The correct option demonstrates the client's willing to have a low risk procedure completed. The remaining options, especially the one dealing with a surgical procedure, lack the element of client cooperation and/or understanding in the decision making process.
You might also like to view...
What do the classification systems NIC and NOC provide?
a. Individualized data banks of treatments related to disease processes b. Standardized language for reporting and analyzing nursing care delivery c. A measure for cost containment within medical institutions d. Specialized interventions for rare diseases
A patient reports epigastric abdominal pain, nausea, and vomiting. The serum amylase level is 450 units/dL. For which health problem should the nurse plan care?
A. Malnutrition B. Gastritis C. Pancreatitis D. Diverticulitis
K.B. is a 65-year-old man admitted to the hospital after a 5-day episode of "the flu" with complaints of dyspnea on exertion, palpitations, chest pain, insomnia, and fatigue. K.B
was diagnosed with Graves' disease 6 months ago and placed on methimazole (Tapazole) 15 mg/day. His other past medical history includes heart failure and hypertension requiring antihypertensive medications; however, he states that he has not been taking these medications on a regular basis. Vital signs (VS) are: 150/90, 124 irregular, 20, 100.2 ° F (37.9 ° C). Admission assessment findings are: height 5 ft, 8 in; weight 132 lb; appears anxious and restless; loud heart sounds; 1+ pitting edema noted in bilateral lower extremities; diminished breath sounds with fine crackles in the posterior bases. K.B. begins to cry when he tells you he recently lost his wife; you notice someone has punched several more holes in his belt so he could tighten it. Which of K.B.'s assessment findings represent manifestations of hypermetabolism?
When an intra-aortic balloon is in place, it is essential for the nurse to frequently assess
a. for a pulse deficit. b. peripheral pulses distal to the catheter insertion site. c. bilateral blood pressures. d. coronary artery perfusion.