A nurse is assisting in the care of an older adult. The client appears to be malnourished and bruising is noted on their arms and legs. The nurse should identify which of the following as the legal responsibility of the nurse?

A. Remind the client that they have been refusing the medication for 5 days: Pointing out the duration of refusal may come across as confrontational and does not respect the client's right to refuse treatment. It can also damage the therapeutic relationship without addressing the underlying concerns about the medication.

B. Inform the client that their provider will contact them to discuss their refusal of the medication: While involving the provider may eventually be necessary, the immediate nursing action should be to document the refusal accurately. The nurse can then inform the provider if needed based on facility policy.

C. Document the client's refusal in the medication administration record: Clients have the legal right to refuse medication, and it is the nurse’s responsibility to document the refusal clearly and objectively. Accurate documentation ensures legal protection for the client and the healthcare team and maintains the integrity of the medical record.

D. Notify the pharmacy about the client's refusal of the medication: Notifying the pharmacy about a single medication refusal is unnecessary unless there are repeated refusals requiring a change in the medication order. The pharmacy’s role is not to manage client compliance but to dispense prescribed medications.

A. Apply restraints according to the facility's standing order: Restraints should never be applied based on a standing order. Each use of restraints requires a specific, immediate provider order following a thorough assessment of the situation.

B. Obtain a PRN prescription for restraints from the provider: PRN (as-needed) orders for restraints are not appropriate. Restraints must be ordered specifically when the need arises, after evaluating less restrictive measures.

C. Stand in front of the client to block them from others in the room: Standing directly in front of a combative client can escalate the situation and put the nurse at risk of injury. Maintaining a safe distance and using de-escalation techniques are safer strategies.

D. Ensure there are enough staff members available for assistance: Ensuring sufficient staff presence is critical when a client becomes combative. It helps ensure the safety of the client, other clients, and staff members, and allows for a coordinated response if physical intervention becomes necessary.