13) A nurse is caring for a client who is unconscious and whose partner is their health care surrogate. The partner wishes to discontinue the client’s feeding tube, but another family member tells the nurse that they want the client to continue receiving treatment. Which of the following responses should the nurse make?

a. Review the chart for nonrestraint alternatives for agitation: While reviewing alternatives is important, the immediate concern is ensuring the safety and well-being of the client by removing the restraints.
b. Inform the unit manager: While it's important to inform the unit manager, the first action should be to address the immediate safety issue by removing the restraints.
c. Speak with the AP about the incident: While it's important to discuss the incident with the assistive personnel, the first priority is to remove the restraints to prevent harm to the client.
d. Remove the restraints from the client’s wrist: This is the correct action to take first to ensure the client's safety and prevent further harm. Afterward, the nurse can address the situation with the assistive personnel and review alternatives for managing the client's agitation.

1. 1. A. Asking the client's son to go to the waiting area is the appropriate first step if elder abuse is suspected. It allows the nurse to speak with the client privately, which can help the client feel more secure and be more open about discussing sensitive issues such as abuse without fear of retaliation or immediate consequences.
      
      B. Filing an incident report is an important step in documenting suspected abuse, but it should not be the first action taken. Documentation should occur after an initial assessment and gathering of information that supports the suspicion of abuse.
      
      C. Treating and discharging the client may address the immediate physical health needs but does not address the potential safety concerns or the suspicion of abuse. Discharging the client back into a potentially harmful environment without further assessment or intervention could place the client at risk of further harm.
      
      D. Asking the client about his injuries with the son present is not advisable if abuse is suspected. The presence of the potential abuser can influence the client's responses and may prevent the client from disclosing abuse due to fear or intimidation.