hard · NCLEX-RN Management of Care
A 42-year-old client who has a court-appointed legal guardian due to a previous severe traumatic brain injury is admitted for an elective orthopedic procedure. At 0900, during the preoperative assessment, the nurse finds the client fully alert, oriented to person, place, time, and situation, and scoring 30/30 on the Mini-Mental State Examination (MMSE). The client states, 'I do not want this surgery, and I refuse to consent.' The legal guardian insists the surgery proceed and signs the consent form. Which of the following actions should the nurse take? Select all that apply.
- Request that the provider order a formal clinical evaluation of the client's current decision-making capacity.
- Prepare the client for the operating room because the legal guardian has signed the consent.
- Document the client's current cognitive status and their explicit verbal refusal of the procedure.
- Inform the surgeon immediately that the client is refusing the procedure despite the guardian's consent.
- Administer the ordered preoperative sedative to help the client comply with the guardian's wishes.
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