Question 1

The nurse is teaching childbirth preparation classes. One woman asks about her rights to develop a birthing plan. Which response made by the nurse would be best?

Accepted Answer

Answer reason: " Clients have the right to participate in decisions about their care, including labor and birth preferences, and the nurse should support informed, autonomous decision-making. This response directly acknowledges the client’s question about rights and opens a therapeutic, educational discussion that can clarify informed consent, choices, and shared decision-making with the partner if desired. It is nonjudgmental and empowers the client rather than challenging motives or deflecting responsibility. Asking about reasons can sound confrontational, and telling her to talk to the provider or write a plan later delays immediate education and advocacy.

Question 2

A client is admitted to a voluntary hospital mental health unit due to suicidal ideation. The client has been on the unit for 2 days and now states "I demand to be released now!" The appropriate action is for the nurse to?

Accepted Answer

Answer reason: Voluntary psychiatric clients generally retain the right to request discharge, and the nurse must follow facility/legal policy to initiate the process and notify the provider for evaluation and appropriate orders. Nursing action should respect client rights while ensuring a safe, legally compliant transition rather than using coercive or inaccurate statements. A “no-suicide contract” is not a reliable safety intervention and does not determine discharge eligibility or reduce suicide risk. Saying the client “cannot be released” without addressing the required legal/provider process is incorrect and escalatory; if the client remains unsafe, the provider can pursue involuntary hold per law/policy.

Question 3

A mother with a Roman Catholic belief has given birth in an ambulance on the way to the hospital. The neonate is in very critical condition with little expectation of surviving the trip to the hospital. Which of these requests should the nurse in the ambulance anticipate and be prepared to do?

Accepted Answer

Answer reason: In Roman Catholic tradition, emergency baptism can be performed by anyone using water and the baptismal formula, which is a common request when a newborn is not expected to survive. This intervention is quick, feasible in an ambulance, and does not create a safety hazard that would interfere with resuscitation. By contrast, refusing treatment would conflict with the neonate’s need for lifesaving measures and is not a typical Catholic directive in emergencies, and items like necklaces may pose airway/line risks during urgent care.

Question 4

Hospital staff requests that the parents with a Greek heritage of a hospitalized infant remove the amulet from around the child's neck. The parents refuse. The nurse understands that the parents may be concerned about?

Accepted Answer

Answer reason: The parents’ refusal is consistent with an intention to maintain a culturally meaningful protective practice. Nursing care should integrate cultural respect while addressing safety concerns (e.g., choking/strangulation risk) through negotiation rather than dismissal. Options about body system balance or developmental delay do not match the specific cultural meaning most associated with an amulet in this context.

Question 5

An unlicensed assistive staff member asks the nurse manager to explain the beliefs of a Christian Scientist who refuses admission to the hospital after a motor vehicle accident. The best response of the nurse would be which of these statements?

Accepted Answer

Answer reason: " Respect for client autonomy and cultural/religious beliefs is central to informed decision-making, even when the client refuses recommended care. Christian Science emphasizes reliance on spiritual means (prayer) for healing and may include declining medical treatment, so this statement accurately reflects the belief system relevant to refusing hospitalization. The other options describe practices more consistent with different traditions or health philosophies (e.g., dietary-based beliefs, prescribed fasting rituals, or structured meditation schedules) rather than the core Christian Science focus. The nurse’s role is to provide accurate, nonjudgmental information and support client rights while ensuring the client is informed about risks and alternatives.

Question 6

A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states "I don't think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects." The nurse should understand that?

Accepted Answer

Answer reason: The nurse is responsible for providing medication teaching within nursing scope and for assessing the client’s concerns (e.g., sedation) and communicating these to the prescriber for possible adjustment. Refusing medication does not remove the client’s right to education; it signals a need for clearer teaching and collaborative planning. It is not optional or left to individual nurse preference, and withholding information to avoid “psychosocial complications” is inconsistent with client rights and safe care.

Question 7

A client refuses to take the medication prescribed because the client prefers to take self-prescribed herbal preparations. What is the initial action the nurse should take?

Accepted Answer

Answer reason: Exploring which herbal product the client is using clarifies the client’s beliefs and reasons for refusal and identifies potential safety risks such as drug–herb interactions or contraindications. This approach supports client autonomy and builds rapport, which increases the chance of shared decision-making and adherence. Education about the prescribed medication and provider notification can follow once accurate information about the herbal preparation and the client’s concerns are obtained.

Question 8

You are caring for a patient who has decided to discontinue treatment. You recognize that the patient is competent to make this decision and support the decision based on which of the following ethical principles?

Accepted Answer

Answer reason: The key clinical requirement is decisional capacity (competence) and adequate information about risks, benefits, and alternatives, after which the patient’s choice is controlling even if clinicians disagree. Justice relates to fairness in distributing resources and care, not the individual’s right to refuse. Fidelity and confidentiality concern keeping commitments and protecting private information, respectively, and do not primarily justify treatment refusal.

Question 9

A patient was restrained because the nurse was trying to prevent the patient from pulling out his IV that was being used to administer antibiotics. Instead of restraining the patient, what should the nurse have done?

Accepted Answer

Answer reason: Restraints are a last resort because they restrict client rights and can cause injury, so nurses should first use the least restrictive measures that maintain safety. Having a trusted family member provide observation and redirection can reduce agitation and prevent device removal without restricting mobility. A sedative used primarily to limit movement is effectively a chemical restraint and requires appropriate clinical indication and provider order, so it is not the preferred first alternative. One-to-one “standing guard” may be appropriate via assigned staff/sitter, but asking family to help monitor is a realistic least-restrictive immediate intervention in this context, and changing to PO antibiotics is a provider decision and may be clinically inappropriate.

Question 10

A client with terminal cancer tells the nurse, "I don’t want any more treatments. I just want to go home." What is the nurse’s best response?

Accepted Answer

Answer reason: ” Competent adults have the right to refuse medical treatment, including at end of life, and the nurse’s role is to respect autonomy while ensuring appropriate communication and follow-up. This response acknowledges the client’s stated preference without coercion, judgment, or imposing the family’s wishes, and it initiates timely provider notification so goals of care, hospice/palliative options, and discharge planning can be addressed. The other responses are inappropriate because they pressure the client to continue treatment, shift decision-making to family, or incorrectly imply the physician must approve the refusal. Communicating the decision supports informed, coordinated care and protects the client’s rights.

Question 11

Which nursing diagnosis describes a clinical judgment that an individual, family, or community is more vulnerable to developing a certain problem than others in the same or similar situation are?

Accepted Answer

Answer reason: The stem is asking specifically for the diagnostic type that indicates vulnerability rather than an actual, present problem or a wellness state. This option is explicitly a risk diagnosis, matching the definition in the question. By contrast, the other options describe actual problems (moral distress, stress overload) or a health-promotion/wellness diagnosis (readiness for enhanced comfort) rather than vulnerability.

Question 12

During the hospital admission process, the client informs the nurse of $25 cash located in the client's wallet. The nurse should?

Accepted Answer

Answer reason: Accurate documentation of client valuables on admission is a risk-management and client-rights measure that establishes an accountable chain of custody and reduces disputes or allegations of theft. Recording the amount present provides a verifiable baseline for later reconciliation if items are sent to security or returned at discharge. Keeping cash in a bedside table is unsafe and increases loss risk, and sending it home with family may be impractical or unsafe and still requires initial documentation. The safer process is to document the valuables and then follow facility policy for securing them (often via hospital security/safe).

Question 13

A client learns she is pregnant and asks the nurse for names of abortion clinics. The nurse does not believe abortion is morally right. What is the nurse’s best response?

Accepted Answer

Answer reason: Clients have the right to make informed decisions about their reproductive care, and the nurse’s role is to provide unbiased, factual information and support autonomy. Providing a standard preprinted resource list meets the request without imposing the nurse’s personal moral beliefs and helps ensure access to appropriate services. Responses that attempt to persuade, shame, or delay the client introduce coercion and violate ethical principles of respect and nonjudgmental care. Deflecting the request to the physician may inappropriately block access to information the nurse can provide and does not address the client’s immediate informational need.

Question 14

After unsuccessful cardiopulmonary resuscitation efforts, the nurse must prepare an Islamic client for the morgue. Which nursing action should the nurse take?

Accepted Answer

Answer reason: In Islam, ritual washing of the body is typically performed by family or designated members of the faith community, so facilitating this is an appropriate nursing action. Simply providing routine postmortem care may violate religious expectations and can increase family distress. Options that instruct the nurse to “do nothing” are unsafe because the nurse still has a duty to coordinate culturally appropriate care and communicate with the family and facility resources.

Question 15

A client undergoes hip replacement surgery and requires assistance to ambulate. The client needs to use the bathroom, but the call light has been left out of reach rendering the client unable to summon staff for assistance. Which client right is violated?

Accepted Answer

Answer reason: Basic patient rights include being treated with dignity and having reasonable access to needed assistance to maintain safety and comfort. Leaving the call light out of reach for a post-hip-replacement client who cannot ambulate independently prevents the client from requesting help for toileting, creating an avoidable risk of falls and incontinence-related distress. This reflects a failure to provide attentive, respectful care that meets basic needs in a timely manner. It is not primarily a restraint issue because no device or method is being used to intentionally limit movement, even though the situation functionally limits the client’s ability to obtain help.

Question 16

The nurse is assessing an elderly client in the emergency room and observes the client to be fearful and noncommunicative. The nurse suspects the client is intimidated by the presence of family members. What is the most appropriate intervention by the nurse?

Accepted Answer

Answer reason: Clients have a right to confidentiality and to speak freely without coercion, and fearfulness with family present raises concern for intimidation or possible abuse. Separating the client from accompanying persons is a priority step to obtain an accurate history and perform a safe assessment, including sensitive screening questions. This intervention is within the nurse’s independent scope and can be implemented immediately without delay. Supportive communication is important but does not remove the barrier to disclosure, and escalating to a supervisor or social work is appropriate after the nurse first ensures a private, safe environment for assessment.

Question 17

During a presurgical admission assessment, the client states, “I’ve told my surgeon that I am Jehovah’s Witness and I won’t accept a blood transfusion.” Which statement by the nurse would be most appropriate?

Accepted Answer

Answer reason:  Clients with decision-making capacity have the right to refuse treatment, including blood products, based on religious beliefs, and the nurse must respect and advocate for that choice. This response affirms autonomy and supports planning for perioperative care consistent with the client’s values (e.g., documenting refusal and notifying the team). Option A incorrectly reframes the refusal as fear rather than a belief-based decision. Option D applies pressure and undermines informed refusal, and option C provides false reassurance without addressing the legal-ethical issue.

Question 18

A new client tells the admissions nurse at a rehabilitation facility, “No one asked me which rehabilitation facility I preferred. I feel as if this entire process took place without my involvement. I was not informed of alternative options.” Which client right is being violated?

Accepted Answer

Answer reason: Clients have the right to be involved in decisions about their care, including being informed of reasonable alternatives and having their preferences considered in discharge planning and placement. Not asking the client which facility they prefer and not presenting other options indicates the client was excluded from planning and decision-making. This is a core client-rights issue tied to shared decision-making and informed choices about care arrangements. Self-determination is related but broader; the specific violation described is the failure to include the client in the care/discharge plan and discuss alternatives.

Question 19

The female nurse is preparing to empty the urostomy bag of a female client who is Muslim. Which statement would be most respectful of the client?

Accepted Answer

Answer reason: "I need to move the covers to the side in order to empty the bag. Can I do this now?" Respectful culturally competent care centers on preserving modesty and obtaining permission before exposing the body or manipulating coverings during intimate care. This statement gives a clear, specific explanation of what the nurse needs to do and explicitly seeks consent, supporting the client’s autonomy and comfort. It also minimizes unnecessary exposure, which is especially important for clients who may have religious modesty preferences. Asking about a spouse’s presence is not the priority and can introduce assumptions; the other options address hydration and nutrition rather than the immediate privacy/consent need.

Question 20

The nurse is caring for the Muslim client in labor. What should the nurse be most aware of as a possible belief of the client?

Accepted Answer

Answer reason: Culturally competent intrapartum care prioritizes modesty, privacy, and respecting family decision-making patterns while still honoring the patient’s rights. In some Muslim families, gender concordance with providers and involvement of the husband/guardian in permissions for male entry may be an important preference, so anticipating this helps prevent distress and supports therapeutic rapport. The nurse should still confirm the client’s own wishes and obtain her consent, but being alert to this possibility supports respectful planning (e.g., offering female staff when feasible). The other options reflect practices more associated with other cultural traditions or are stereotyped pain-expression assumptions rather than a common, specific Muslim belief.

Question 21

The primiparous client, who delivered a term newborn, is a lesbian, achieved her pregnancy via artificial insemination, and is in a monogamous relationship with a female partner. Which intervention should the nurse add to the newborn’s care plan?

Accepted Answer

Answer reason: Family-centered maternity/newborn nursing prioritizes inclusion of the client’s chosen support persons and promotes bonding, attachment, and caregiver competence. Involving the partner supports equitable, nonjudgmental care and respects the client’s family structure while improving readiness for newborn care after discharge. Excluding or isolating the partner is discriminatory and can increase stress and impair support during the postpartum period. Privacy and confidentiality should be maintained, but they do not justify avoiding acknowledgment of the relationship or restricting appropriate family participation in care.

Question 22

The client diagnosed with schizoaffective disorder was recently treated for a major depressive episode. Following a 72-hour involuntary commitment, the client is stable, no longer displaying suicidal ideation, and asking to leave the hospital. Which client right should the nurse consider while deciding if the client can be discharged?

Accepted Answer

Answer reason: After an involuntary hold expires, continued hospitalization must be clinically justified by ongoing danger to self/others or grave disability; if the client is stable and no longer suicidal, discharge planning and step-down care should be considered. This right specifically guides the decision about whether inpatient confinement is still necessary versus a less restrictive alternative. The other options address different rights (e.g., refusal of treatment, restraint use, service planning) but do not directly determine whether continued confinement is justified.

Question 23

An alert, oriented, adult Jehovah Witness client is refusing blood even though he realizes he could die. The wife, who is not a believer, asks that blood be given. How should the situation be handled?

Accepted Answer

Answer reason: A competent adult with decision-making capacity has the legal and ethical right to refuse any treatment, even if refusal may result in death. The nurse’s duty is to respect autonomy and ensure the refusal is informed (risks, benefits, alternatives) and documented; a spouse cannot override the patient’s expressed wishes. Refusal of transfusion on religious grounds is not evidence of suicidality and does not justify involuntary treatment or “protective custody.” An advance directive may support understanding of preferences, but it is not required when the current patient is alert, oriented, and clearly refusing.

Question 24

A prison inmate is brought to the emergency department with complaints of chest pressure that radiates up the jaw and down the left arm. The nurse overhears another employee speaking rudely to the inmate client. Acting as the client’s advocate, the nurse tells the employee privately that all clients are to be treated with equal respect and dignity. Which client right has the nurse protected?

Accepted Answer

Answer reason: Clients retain the right to be treated with dignity and without discrimination regardless of incarceration status. The nurse’s private correction of rude behavior directly advocates for respectful, considerate treatment as a basic patient right and standard of professional conduct. Privacy and confidentiality relate to protecting personal information and limiting exposure, which is not the primary issue described. Free speech is unrelated to ensuring professional, non-abusive communication and equitable care delivery in the clinical setting.

Question 25

The nurse notices that a client’s bedside privacy curtain has been left partially open during the client’s bath. Which is the best action for the nurse to take to ensure the client’s right to privacy?

Accepted Answer

Answer reason: Protecting patient privacy and dignity requires taking immediate corrective action to prevent further exposure. Closing the curtain is the most direct, timely intervention that restores privacy and reduces risk of additional breaches. Telling the client about potential exposure does not fix the current problem and can increase distress without addressing the immediate safety/rights issue first. “No action” options are inappropriate because privacy is required regardless of whether the client noticed or how many visitors are present.

Question 26

A client presents a Durable Power of Attorney for Health Care designating the client’s niece as the person to make health care decisions for the client should the client become incapacitated and unable to make informed health care decisions. The Durable Power of Attorney identifies the niece as the?

Accepted Answer

Answer reason: A durable power of attorney for health care (health care proxy) authorizes a designated agent to make medical decisions when the client lacks decision-making capacity. This authority is limited to health care choices (consent/refusal, treatment preferences, end-of-life decisions) unless a separate financial power of attorney document is executed. Next of kin status does not override a properly executed health care proxy when the client is incapacitated. Responsibility for payment is not created by being named as a health care decision-maker.

Question 27

A hospital client with abdominal cancer refuses surgical treatment and chemotherapy and asks about options for hospice home care. Later, the client’s daughter asks the case manager to talk the client into agreeing to surgery and chemotherapy treatment. The case manager explains to the daughter that this violates which client right?

Accepted Answer

Answer reason: Competent adults have the ethical and legal right to make autonomous choices about accepting or refusing medical treatment. Attempting to “talk the client into” unwanted surgery/chemotherapy undermines autonomy and can cross into coercion rather than supporting informed decision-making. Hospice is a legitimate care option, and choosing comfort-focused care over disease-directed therapy is within the client’s rights. Option D is related, but the broader, primary right being violated here is autonomy/self-determination in making health care decisions.

Question 28

A 57-year-old client with acute arterial occlusion of the left leg undergoes an emergency embolectomy. Six hours later, the nurse isn’t able to obtain pulses in his left foot using Doppler ultrasound. She immediately notifies the physician, who asks her to prepare the client for surgery. As the nurse enters the client’s room to prepare him, he states that he won’t have any more surgery. What is the most appropriate initial action of the nurse?

Accepted Answer

Answer reason: The surgeon must be made aware immediately because loss of distal pulses after embolectomy suggests re-occlusion or acute ischemia with risk of limb loss, making time-critical decision-making essential. Teaching about risks is appropriate but is not the nurse’s first action when a major change in the plan of care occurs and the provider needs to evaluate and speak with the client. Documentation is important but follows immediate communication and intervention planning, not before.

Question 29

The client experiences nausea after an oral dose of cephalexin, and interventions for nausea are unsuccessful. When the nurse attempts to administer the next dose of cephalexin, the client adamantly refuses to take it. Which nursing intervention is best?

Accepted Answer

Answer reason: A competent client has the right to refuse any medication, and the nurse must respect that decision while ensuring the prescriber is notified so therapy can be safely revised. Persistent nausea despite attempted measures represents an intolerable adverse effect and creates a high likelihood of continued nonadherence if the same drug is pushed. The safest nursing action is to communicate the refusal and side effect to the prescriber and seek an alternative antibiotic or regimen. Continuing to try comfort measures or timing changes does not address the refusal and risks delaying effective treatment.

Question 30

The RN is informed by the NA that the client, hospitalized last evening with chest pain, plans to leave right now because the pain is gone and “nobody has done anything anyway.” Which is the nurse’s best action?

Accepted Answer

Answer reason: The nurse’s priority is to directly assess the client’s decision-making, clarify concerns, and provide information needed for an informed choice before escalating or delegating. A client wanting to leave after chest pain relief may still be at high risk for ongoing ischemia, dysrhythmias, or missed evaluation, so immediate RN-client communication is essential. This approach uses therapeutic communication to address perceived neglect (“nobody has done anything”) and can reduce the likelihood of an unsafe departure by clarifying tests, timing, and next steps. Calling the provider can be appropriate after the RN has assessed and attempted to resolve concerns, but it is not the first best action. Involving the NA to persuade the client or help the client pack misuses delegation and fails to protect the client’s rights to education and informed decision-making.

Question 31

A client with a Do Not Resuscitate/Do Not Intubate order in the medical record becomes unresponsive and a code blue is called. The code team arrives and the physician is preparing to intubate the client. What action should the nurse take regarding the DNR/DNI order?

Accepted Answer

Answer reason: A valid DNR/DNI is a legally and ethically binding expression of the patient’s treatment limits and must be honored during emergencies. The nurse’s priority is rapid advocacy and communication so the team can immediately stop or avoid prohibited interventions (e.g., intubation) and pivot to allowed comfort-focused measures. Proceeding with ACLS or preparing for intubation risks providing unwanted, nonconsented care that violates the patient’s rights. The physician does not unilaterally override an existing, properly documented DNR/DNI in the moment without an appropriate legal basis and order change.

Question 32

A client with an executed advance directive specifying “do not resuscitate, do not intubate” in the medical record becomes unresponsive during a bed bath, at which time the nursing assistant activates the hospital code blue system. The client’s primary nurse arrives quickly at the bedside to find the nursing assistant performing cardiopulmonary resuscitation as the code team enters the client’s room. Which action by the nurse is most important in protecting the client’s right to self-determination?

Accepted Answer

Answer reason: A valid DNR/DNI order is an expression of the client’s autonomous choices and must be honored to protect self-determination. Continuing chest compressions or preparing for advanced airway management would directly violate the documented directive and constitute unwanted treatment. The priority nursing action is to immediately stop resuscitative efforts and inform the code team that DNR/DNI is in place, then follow facility policy for verification and documentation. Actions that support CPR or intubation are unsafe and unethical because they escalate interventions the client specifically refused.

Question 33

A client’s surgeon discusses the option of surgery and related benefits and risks with the client and the client’s family. Which statement by the client demonstrates the client understands the right to make decisions regarding treatment and the proposed plan of care?

Accepted Answer

Answer reason: The core principle is client autonomy: after receiving adequate disclosure, the client has the right to accept or refuse a proposed treatment and to consider alternatives. This statement shows the client understands that informed decision-making belongs to the client, not the provider or family. It also reflects awareness that options exist beyond the proposed surgery, which is central to informed consent and shared decision-making. In contrast, statements implying compliance due to surgeon authority, family pressure, or fear of speaking up indicate misunderstanding of client rights and compromised autonomy.

Question 34

An elderly client from a long-term care facility arrives in the emergency department by ambulance with altered level of consciousness. The physician instructs the respiratory therapist to prepare for intubation. The nurse discovers a Do Not Resuscitate (DNR) bracelet on the client’s wrist during the initial assessment. Which immediate action should the nurse take to appropriately advocate for this client?

Accepted Answer

Answer reason: A DNR reflects the client’s right to refuse specific life-sustaining interventions and must be honored once recognized and verified per facility policy. The nurse’s immediate advocacy is to promptly communicate this critical information to the provider directing the plan of care so orders can be clarified before potentially unwanted interventions proceed. Contacting family may be appropriate later for documentation/confirmation if needed, but it should not delay notifying the provider and preventing an immediate rights violation. Assisting with intubation without first addressing the DNR risks initiating treatment inconsistent with the client’s expressed wishes.

Question 35

A nurse is taking a client’s medical history in the emergency room. The nurse asks if the client has an advance directive. The client responds by saying,” I have heard of advance directives, but I do not have one. What is an advance directive?” What is the nurse’s best response to the client’s question?

Accepted Answer

Answer reason: An advance directive is a form of a living will. It specifies your wishes regarding health care and treatment options should you become incapacitated. Advance directives are legal documents that communicate a person’s preferences for future medical care if they lose decision-making capacity. This option accurately focuses on healthcare and treatment decisions, which is the core purpose of an advance directive (e.g., living will, durable power of attorney for healthcare). Options that emphasize finances/personal effects confuse advance directives with estate planning or financial power of attorney. The burial-focused choice describes postmortem wishes rather than medical decision-making while the client is alive but incapacitated.

Question 36

A client asks to view the client’s medical records. Which response made by the nurse is most appropriate?

Accepted Answer

Answer reason: Clients have a legal right to access their own health information, and nursing responses should support autonomy and informed decision-making. The best response acknowledges this right and offers assistance with understanding the information, which promotes safe, informed participation in care. Requiring an attorney or delaying access until discharge imposes unnecessary barriers and is not consistent with client-rights standards. Questioning motives or implying litigation is nontherapeutic and can be perceived as intimidation, violating professional communication expectations.

Question 37

The client’s physician orders a blood transfusion for a client whose hemoglobin level is 5.0 mg/dL. The nurse informs the client that blood will be drawn for a type and cross-match prior to the blood transfusion. The client avoids eye contact with the nurse, then states,” I am a Jehovah’s Witness. I thought that was on my chart.” The nurse demonstrates the role of client advocate by which response to the client?

Accepted Answer

Answer reason: I will place that information in your medical record. You have the right to refuse treatment which conflicts with your beliefs. Would you like to speak with your physician about other treatment options? The core principle is respect for client autonomy and informed refusal, even when the recommended treatment is life-sustaining. The nurse acts as an advocate by ensuring the client’s stated religious preference is documented, affirming the client’s legal/ethical right to refuse, and facilitating provider discussion of acceptable alternatives. This response supports shared decision-making without coercion and promotes continuity and safety by communicating crucial information to the team. In contrast, pressuring the client to accept the transfusion or directing them to comply undermines autonomy and advocacy.

Question 38

A client in the intensive care unit is alert and oriented, but loud and verbally abusive to all health care personnel who enter the client’s room. Multiple staff members including the charge nurse have spoken to the client about the inappropriate behavior, but all attempts have been ineffective. The client has lorazepam (Ativan) IV ordered as needed for disorientation and agitation. Which client right would be violated if the nurse were to administer the medication to the client under these circumstances?

Accepted Answer

Answer reason: Chemical restraints are medications used to control behavior or restrict freedom of movement when not medically indicated for the patient’s condition. Here, the PRN lorazepam is ordered specifically for disorientation and agitation, but the client is alert and oriented and the proposed use is to manage verbal abusiveness toward staff. Administering a sedative in that context would constitute an unreasonable chemical restraint and violates the patient’s right to be free from unwarranted restraints. The appropriate response is to use de-escalation, set limits, involve the provider/security per policy, and medicate only when clinical criteria for agitation/disorientation are present and documented.

Question 39

A client is referred to a surgeon by the healthcare provider. After meeting the surgeon, the client decides to consult with a different surgeon about treatment options. The nurse supports the client’s action, utilizing which ethical principle?

Accepted Answer

Answer reason: Supporting the client’s decision to consult another surgeon reflects respect for self-determination and control over treatment choices. Beneficence focuses on acting for the client’s good but does not specifically address the client’s right to choose among options. Veracity concerns truth-telling and privacy concerns confidentiality, neither of which is the primary issue in this scenario.

Question 40

A client has been admitted to the oncology unit and has a large amount of cash, several credit cards, and several pieces of expensive-looking gold jewelry in her possession. Which action by the nurse is most appropriate?

Accepted Answer

Answer reason: This option uses an approved chain of custody (family or hospital security/safe) and includes patient education so the client can make an informed decision. The “hide it” options create a high risk of theft and disputes and do not provide secure storage. Having staff store valuables in a unit office is typically not policy-based and can expose the nurse and facility to allegations of loss or mishandling.

Question 41

Despite a patient stating that they don’t want an IV, the nurse holds them down and attempts to start an IV, causing a large hematoma. What type of tort has the nurse committed?

Accepted Answer

Answer reason: The patient explicitly refused the IV, so proceeding to restrain and attempt the procedure constitutes an unauthorized touching regardless of the nurse’s intent. The resulting hematoma supports that physical contact occurred and caused harm, but harm is not required to establish the tort. A common distractor is assault, which is creating fear of imminent harmful contact; here the key act is the actual nonconsensual contact/procedure attempt.

Question 42

What term is used to describe any legal documents which communicate an individual’s choices regarding medical care should they become incapacitated?

Accepted Answer

Answer reason: This category includes documents like a living will (specific treatment wishes) and durable power of attorney for healthcare (appointing a surrogate decision-maker). A DNR is a specific medical order about resuscitation, not the broad term for all such legal documents. Therefore, the most inclusive and correct term is the one that covers all these forms.

Question 43

It is the nurse’s responsibility to act as client advocate. What is the definition of client advocacy?

Accepted Answer

Answer reason: Client advocacy involves protecting and supporting the client’s rights, preferences, and autonomy, including speaking up on their behalf and ensuring their wishes are respected in care decisions. It is grounded in ethical principles such as autonomy and informed consent. Option A violates autonomy by prioritizing provider beliefs over the client’s wishes. Option C provides false reassurance. Option D is incorrect because clients generally have the right to refuse treatment, even if it may be detrimental to their health.

Question 44

The nurse is discussing the TBI Act at a support group meeting. Which statement best explains the act?

Accepted Answer

Answer reason: The TBI Act focuses on protecting and supporting the rights of individuals with traumatic brain injury through community-based services, advocacy, and public policy. It aligns most closely with client rights and advocacy rather than legal liability or responsibilities. Option B refers to the ADA. Option C is incorrect because the act does not guarantee universal access. Option D misrepresents the scope of the legislation.

Question 45

An intubated client admitted to the intensive care unit appears anxious and fearful of the equipment in the room. The nurse observes this and takes the time to explain each piece of equipment and its role in providing care to the client. This is an example of the nurse acting as a client advocate by?

Accepted Answer

Answer reason: Client advocacy includes ensuring that clients are informed, supported, and able to understand their care. By explaining the equipment, the nurse reduces anxiety, promotes understanding, and supports the client’s psychological comfort, which reflects advocacy. Options B and C are important aspects of care but are not demonstrated here. Option D involves decision-making and respecting treatment preferences, which is not the focus of this scenario.

Question 46

A nurse on the neurology unit cares for a client who is alert and oriented x3, neurologically intact, and requests to leave. When the primary healthcare provider refuses, the client becomes upset and makes attempts to leave. The provider orders haloperidol to chemically restrain the client. Which action by the nurse is most appropriate at this time?

Accepted Answer

Answer reason: Chemical restraint requires a clear safety justification and cannot be used to prevent elopement solely because a provider disagrees with the decision. Presenting AMA paperwork supports informed refusal by documenting that the client understands the risks, benefits, and alternatives and is choosing to leave. Escalation or psychiatric evaluation may be considered only if there are specific findings suggesting impaired decision-making; none are provided here.

Question 47

The nurse honestly answers a patient who asks about the possible side effects of a medication. Which ethical principle is the nurse using?

Accepted Answer

Answer reason: By honestly discussing potential medication side effects, the nurse supports informed decision-making and prevents deception or withholding of relevant facts. This directly aligns with respecting the patient’s right to know information material to consent and ongoing treatment choices. Autonomy is supported by truthful information, but the specific principle being demonstrated is truth-telling rather than decision-making itself. Beneficence and nonmaleficence focus on doing good and avoiding harm, which are broader treatment aims rather than the act of honest disclosure.

Question 48

The nurse on a locked psychiatric unit is administering morning medications to a patient with schizophrenia. The patient refuses and says, “I’m not going to take that!” What is the nurse’s BEST response?

Accepted Answer

Answer reason: The nurse’s best response acknowledges autonomy while accurately indicating that further evaluation (eg, provider reassessment and legal/second-opinion process per policy) may occur if refusal places the patient or others at risk. This approach is therapeutic and noncoercive while still addressing safety and the potential need for emergent medication routes under proper authorization. The other options are coercive, inaccurate about client rights, or use persuasion that undermines informed decision-making and therapeutic communication.

Question 49

A 101-year-old patient with end stage renal disease is refusing to take her medications “because they don’t work and I’m going to die soon anyway.” Which of the following responses is most correct?

Accepted Answer

Answer reason: You have the right to refuse any of your medications. Let’s talk about what’s been prescribed to you Competent adults have the right to refuse treatment, and the nurse must respect autonomy while ensuring the decision is informed. This response acknowledges the patient’s right, avoids coercion, and opens therapeutic communication to explore beliefs, goals of care, symptoms, and misunderstandings about medication benefits. It also creates an opportunity to assess decision-making capacity and provide education or alternatives aligned with the patient’s values, including palliative priorities if appropriate. The other options use threats, false legal claims, or appeals to authority, which violate client rights and can escalate distress rather than support informed refusal.

Question 50

A patient has told the nurse they are going to leave the hospital against medical advice. Which of the following actions by the nurse is inappropriate?

Accepted Answer

Answer reason: Security is generally indicated only when there is an immediate safety threat or the patient lacks decision-making capacity and is on an appropriate legal/medical hold. Appropriate steps include notifying the provider, explaining risks/benefits and alternatives, documenting the discussion, and completing AMA paperwork when possible. Removing invasive lines is also appropriate to reduce risk of bleeding, infection, or embolus once the patient is determined to be leaving.

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