A nurse is caring for a 9-year-old child at a clinic.

Exhibits

The nurse should determine that the assessment findings are consistent with which of the following conditions?
For each potential condition, click to specify if the assessment findings are consistent with a sprain, a fracture, or a dislocation. Each finding may support more than 1 condition.

Rationale:
A. A financial power of attorney manages financial affairs, not medical decisions. Health care decisions are instead guided by a health care proxy or durable power of attorney for health care, as outlined in the client’s advance directives.

B. The Patient Self-Determination Act upholds the client’s autonomy by allowing them to accept or refuse medical or life-sustaining treatment. This includes the right to decline care, even if such refusal may lead to death, ensuring that personal values and wishes guide end-of-life care.

C. Advance directives can be revised or revoked by the client at any time, regardless of notarization, as long as the client remains mentally competent. The document reflects current wishes and is not legally binding indefinitely.

D. Family members cannot alter a legally valid advance directive. The document represents the client’s own decisions, and only the client can modify or revoke it while competent to do so.

Rationale:
A. "Report bleeding that saturates the client's dressing.": Excessive or saturating bleeding from a postoperative abdominal incision may indicate hemorrhage or disruption of the surgical site and requires immediate provider notification.

B. "Ensure the client's urinary output is no less than 20 mL per hour.": The expected minimum urinary output for an adult after surgery is at least 30 mL per hour, which reflects adequate renal perfusion and fluid balance. A urine output of 20 mL per hour is too low.

C. "Expect the client to have a palpable distended bladder following surgery.": A distended bladder is not expected postoperatively and may signal urinary retention, a common complication due to anesthesia or opioids.

D. "Maintain the client in a supine position for 24 hours following surgery.": Keeping the client supine for 24 hours increases the risk of respiratory complications, including atelectasis and pneumonia. The nurse should encourage early ambulation and semi-Fowler’s positioning.