A nurse is caring for a patient hospitalized with acute kidney injury (AKI). The healthcare provider has ordered daily weights and strict intake and output monitoring. The nurse notes that the patient has gained 3 pounds over the past 48 hours, with minimal urine output recorded during that time. What does this assessment finding most likely indicate?

The patient is experiencing improved nutritional status

The weight gain is expected and not clinically significant

The patient is showing early signs of recovery from AKI

The patient may be retaining fluid due to AKI

Answer and Explanation

The Correct Answer is D

Choice A reason: Improved nutritional status could cause weight gain but is unlikely in AKI with minimal urine output. AKI patients often have anorexia or dietary restrictions, and weight gain from nutrition would not align with oliguria, which suggests fluid retention rather than increased tissue mass from improved nutrition.

Choice B reason: A 3-pound weight gain in 48 hours with minimal urine output is clinically significant in AKI, indicating fluid retention. Normal weight fluctuations are minimal, and this rapid gain, coupled with oliguria, suggests impaired kidney function, potentially leading to fluid overload complications like hypertension or pulmonary edema.

Choice C reason: Early AKI recovery involves increased urine output (diuresis phase), not minimal output. Weight gain with oliguria indicates ongoing kidney dysfunction, not recovery. Recovery would show improved glomerular filtration and urine production, reducing fluid retention, making this finding inconsistent with AKI recovery.

Choice D reason: In AKI, minimal urine output (oliguria) reflects impaired kidney filtration, leading to fluid retention. A 3-pound weight gain in 48 hours corresponds to approximately 1.5 liters of fluid, indicating fluid overload. This can cause hypertension, pulmonary edema, or heart failure, making fluid retention the most likely explanation.

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Correct Answer is C

Explanation

Choice A reason: Coercing treatment violates the voluntary client’s autonomy. Legally, voluntary patients can refuse medication unless they pose imminent danger, requiring involuntary commitment. Manipulation or disruption does not meet legal criteria for forced treatment, as mental health laws prioritize patient rights absent clear harm risks.

Choice B reason: A 302 (involuntary commitment) requires evidence of imminent danger to self or others, not just disruptive behavior. Family petitions cannot override this legal threshold without clinical justification, and manipulation alone does not qualify, making this option incorrect for enforcing treatment in a voluntary client.

Choice C reason: As a voluntary client, the individual retains the right to refuse treatment unless deemed a danger to self or others. Mental health laws protect autonomy, and manipulation or lack of progress does not justify forced medication, making refusal a legal right in this scenario.

Choice D reason: Involuntary commitment by a doctor requires evidence of imminent danger or inability to care for oneself, not just disruptive behavior or nonadherence. Without such criteria, the client’s voluntary status protects their right to refuse, making involuntary commitment legally inappropriate in this situation.

A. When the client violates the nurse’s boundaries B. If threats are made to an identifiable third party C. Whenever the client becomes aggressive D. At any time a client does not agree with the nurse

Correct Answer is B

Explanation

Choice A reason: Violating a nurse’s boundaries, such as inappropriate behavior, does not legally mandate breaching confidentiality. Ethical responses involve setting boundaries or reporting within the care team, but confidentiality is protected unless harm to others is threatened, making this situation insufficient for a legal breach.

Choice B reason: Nurses are legally obligated to breach confidentiality when a client makes credible threats to harm an identifiable third party (Tarasoff duty). This protects potential victims by ensuring warnings or interventions occur, balancing patient confidentiality with public safety, as harm prevention takes precedence in mental health law.

Choice C reason: Client aggression does not automatically warrant breaching confidentiality unless it involves specific threats to identifiable individuals. Aggression is managed within the care setting, and confidentiality is maintained unless legal criteria, like imminent harm to others, are met, making this option incorrect.

Choice D reason: Disagreement with the nurse does not justify breaching confidentiality. Ethical care respects client autonomy, and confidentiality is protected unless legal exceptions, like threats or court orders, apply. Disagreement is managed through therapeutic communication, not by disclosing private information, making this an invalid reason for breach.

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

When is a nurse legally obligated to breach confidentiality?

Correct Answer is B

Explanation

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