The nurse is assessing an adult client when suddenly the client refuses to continue the examination. Which action by the nurse is the priority?
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.
Correct Answer: 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. 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. 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. 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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