A nurse is caring for an infant who has pertussis. Which of the following precautions should the nurse implement?

The nurse should maintain continuous observation of the adolescent.

Choice A reason:

The first and most crucial action when a patient expresses an intention to self-harm is to ensure their safety. By maintaining continuous observation, the nurse can closely monitor the adolescent's behavior and intervene promptly if any signs of self-harm emerge. This action helps prevent immediate harm and allows for timely interventions.

Choice B reason:

Applying wrist restraints to the adolescent (Choice B) would not be appropriate in this situation. Restraints are typically used as a last resort for patients who pose a danger to themselves or others and only when less restrictive measures have failed. In the case of self- harm, using restraints can increase the patient's distress and potentially worsen the situation.

Choice C reason:

Collecting data about the adolescent's mental status (Choice C) is an essential step in understanding their overall condition, but it should not be the first action taken. While gathering data is important for a comprehensive assessment, immediate safety concerns must take precedence.

Choice D reason:

Obtaining consent from the adolescent's guardian for the application of restraints (Choice D) is not the first priority when the patient expresses an intention to self-harm. The focus should be on ensuring the patient's immediate safety, and consent for restraints may be necessary only if other interventions prove inadequate.

Choice A reason:

The nurse should inform the adolescent of their right to refuse treatment because respecting the patient's autonomy and right to make their own decisions about their healthcare is essential. This is especially true for an adolescent who is living on their own, as they have the legal capacity to make their medical decisions independently.

Choice B reason:

This statement is incorrect because, in most jurisdictions, adolescents who live on their own are considered emancipated minors, meaning they have the legal right to make their medical decisions without involving a parent or guardian. Requiring a parent or guardian's consent would not be applicable in this situation.

Choice C reason:

This statement is incorrect and irrelevant to the situation. Marriage status does not determine an individual's ability to make their own health care decisions. Regardless of marital status, an adolescent living on their own has the right to make their medical choices.

Choice D reason:

This is the correct choice. The nurse should emphasize the adolescent's right to refuse treatment if they wish to do so. It is crucial to respect their autonomy and ensure that they are fully informed about the potential consequences of their decision. However, the nurse should also provide relevant information about the treatment's benefits and risks to help the patient make an informed decision.