A nurse is caring for a client who speaks a different language than the nurse. The client's partner tells the nurse that the client would like to go home against medical advice (AMA).
Which of the following actions should the nurse take?
Have the client's partner sign an AMA form
Discharge the client and notify the health care provider.
Ask the partner to reiterate the consequences of leaving AMA to the client.
Request the services of an interpreter to determine the client's wishes.
The Correct Answer is D
Effective communication with the client is crucial to understand their desires and provide appropriate care. When faced with a language barrier, it is important to use professional interpreter services to ensure accurate and clear communication. By requesting an interpreter, the nurse can obtain a clear understanding of the client's wishes and concerns regarding leaving AMA.
Without clear communication with the client, it is not appropriate to assume that the partner can make decisions on their behalf or sign an AMA form. It is important to directly ascertain the client's wishes.
Discharging the client without understanding their wishes and providing appropriate education or interventions could potentially put the client at risk. It is necessary to have a clear understanding of the client's desires before taking any action.
Asking the partner to reiterate the consequences of leaving AMA to the client: While educating the client and their partner about the consequences of leaving AMA is important, it is not sufficient in this situation. The nurse needs to directly communicate with the client to understand their wishes and concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Atorvastatin is a medication used to lower cholesterol levels in the blood. One of the potential adverse effects of atorvastatin is myopathy, a condition characterized by muscle pain, weakness, and tenderness. In severe cases, myopathy can progress to rhabdomyolysis, a potentially life-threatening condition in which muscle breakdown products are released into the bloodstream and can cause kidney damage.
Therefore, the nurse should instruct the client to monitor for muscle pain, weakness, or tenderness and report these symptoms to the healthcare provider immediately. Hypoglycemia, palpitations, and daytime drowsiness are not commonly associated with atorvastatin use and would not require immediate reporting to the healthcare provider.
Correct Answer is C
Explanation
A.While monitoring the client's physical condition, including range of motion, is important, it typically needs to be done more frequently than every 60 minutes. The Joint Commission and other regulatory bodies often recommend continuous observation and checks every 15 minutes.
B.Typically, a provider's order for restraints must be obtained immediately or within a very short time frame (often within an hour), not 48 hours. Regulations vary but generally require prompt notification and authorization.
C.Restraints should only be used as a last resort and for the shortest duration possible. The goal is to ensure the client's safety and the safety of others while minimizing the use of restraints. Removing the restraints as soon as the client is calm and no longer a threat to themselves or others is essential to respecting the client's rights and promoting their dignity.
D.Offer the client a nutritious snack every 4 hr.: While providing nutrition and hydration is important, the primary focus immediately after applying restraints should be on the client's safety and the frequent assessment of their condition. Offering a snack every 4 hours is not the immediate priority in this context.
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