A nurse is reviewing an electronic medical record to determine if a client’s rights have been violated by another member of the healthcare team. Which finding will the nurse identify that would indicate a violation of the client’s rights?

Choice A reason: In the oliguric phase of AKI, kidney function is severely impaired, reducing potassium excretion. This leads to hyperkalemia, which disrupts cardiac electrical activity, potentially causing life-threatening arrhythmias or cardiac arrest. Elevated potassium levels are a hallmark of this phase due to decreased glomerular filtration rate and impaired tubular secretion.

Choice B reason: Urine output of 2000 mL in 24 hours indicates polyuria, characteristic of the recovery phase of AKI, not the oliguric phase, where output is typically less than 400 mL/day. High urine output suggests restored renal function, which is not expected in the oliguric phase, where kidneys fail to filter adequately.

Choice C reason: Tachycardia may occur in AKI due to fluid overload causing increased cardiac workload or electrolyte imbalances like hyperkalemia affecting heart rhythm. However, it is a secondary symptom and less specific than hyperkalemia, which directly results from impaired renal excretion and poses a more immediate risk to cardiac function.

Choice D reason: Tenting of the skin indicates dehydration, which may precede AKI but is not typical in the oliguric phase, where fluid retention is more common due to reduced urine output. Fluid overload leads to edema, not dehydration, making skin tenting an unlikely finding in this phase of AKI.

Choice A reason: One-to-one observation for aggressive behavior is a standard safety measure to prevent harm, aligning with the right to safe care. It does not violate client rights when justified by clinical need, as it prioritizes protection without restricting autonomy unnecessarily, making it an appropriate intervention.

Choice B reason: Using physical restraints to prevent self-harm is permissible when less restrictive measures fail, aligning with the right to safety. If properly documented and justified, it does not violate rights, as mental health laws allow restraints for imminent danger, making this action compliant with client rights.

Choice C reason: Searching belongings at admission is standard in psychiatric settings to ensure safety (e.g., removing contraband). This practice, when conducted respectfully and per policy, does not violate client rights, as it prioritizes a safe therapeutic environment for all patients and staff on the unit.

Choice D reason: Lack of documentation of treatment benefits and options violates the right to informed consent. Clients must be informed about treatment rationale and alternatives to make autonomous decisions. Failure to document this breaches legal and ethical standards, undermining the client’s ability to participate in their care, making it a rights violation.