Question

A nurse is caring for four clients in an emergency department. The nurse should identify Which of the following clients can give informed consent?

a.SomnolenceAlcohol withdrawal is an acute condition that occurs following a sudden cessation of alcohol intake. It can occur in a client who has a history of alcohol use disorder or after a period of heavy alcohol intake. Manifestations include agitation, insomnia, and irritability.
b.Blood pressure 154/96 mm HgMY ANSWERPhysical manifestations of alcohol withdrawal occur in addition to psychological effects. A client who is experiencing alcohol withdrawal is expected to have hypertension, tachycardia, and fever greater than 38.3° C (101° F). It will be important for the nurse to rule out infection in the client who has a fever.
c.Pinpoint pupilsA client who is experiencing alcohol withdrawal can experience profuse sweating and dilated pupils as a part of the autonomic nervous system's response. The autonomic nervous system is responsible for management of homeostasis. It has sympathetic and parasympathetic effects impacting the pupils of the eyes as well as the circulatory, respiratory, gastrointestinal, genitourinary, and integumentary systems.
d.Blood glucose 210 mg/dLMedical complications occur as a result of alcohol withdrawal, including hypoglycemia. As the glycogen stores in the liver are depleted from extensive alcohol intake, the body's ability to produce glucose is impaired. As a result, blood glucose levels fall, often requiring parenteral dextrose to be administered. Associated manifestations of hypoglycemia are also seen in clients experiencing alcohol withdrawal, such as shakiness and diaphoresis. The nurse should monitor blood glucose levels and encourage carbohydrate intake.

Answer 1

The nurse should identify the client with blood pressure 154/96 mm Hg as the one who can give informed consent.

Option B is correct

The other clients may be experiencing various physical and psychological manifestations, they are not in a state of mind to make informed decisions about their medical care. The client with somnolence is experiencing drowsiness and altered consciousness, which would impair their ability to understand and make informed decisions.

The client with blood pressure 154/96 mm Hg is the most likely to be able to provide informed consent because they are not experiencing any significant physical or psychological impairments that would affect their ability to understand and make decisions about their medical care.