A nurse is reviewing the medical record of a client who had abdominal surgery 2 days ago. The nurse should identify that which of the following findings indicates the client is at risk for delayed wound healing?

Choice A reason: Thinking about wanting the procedure shows indecision, not consent understanding. Informed consent requires comprehension of the procedure, risks, and benefits, ensuring voluntary agreement. Contemplation alone is incomplete, failing to confirm the client’s grasp of the consent form’s legal purpose.
Choice B reason: Stating that signing indicates permission reflects understanding of informed consent, which documents voluntary agreement after receiving procedure details, risks, and benefits. This aligns with ethical and legal standards, confirming the client’s comprehension of the consent form’s role in authorizing surgery.
Choice C reason: Asking about risks indicates engagement but not consent understanding. It suggests a need for more information, not confirmation of the form’s purpose. While important, it does not reflect comprehension of the consent process as clearly as acknowledging the act of signing.
Choice D reason: Wanting to discuss concerns with the doctor shows the client seeks clarification, not that they understand the consent form’s purpose. It indicates an ongoing process, not confirmation of the form’s role in granting permission, unlike acknowledging the signing’s significance.

Choice A reason: Removing restraints immediately risks safety, as the client’s calm state may not be sustained. Restraints require gradual removal after ensuring sustained behavioral stability, per facility policy and safety standards. Frequent monitoring is needed to assess ongoing safety, making this action premature and potentially unsafe.
Choice B reason: Encouraging group therapy is inappropriate while the client remains in restraints, as it does not address the immediate need to evaluate their behavior for safe restraint removal. Therapy may be beneficial later, but ongoing monitoring is the priority to ensure safety and compliance with restraint protocols.
Choice C reason: Continuing to monitor the client every 15 minutes ensures safety while assessing sustained calm and cooperative behavior. This adheres to restraint protocols, which require frequent checks to evaluate the need for continued restraint, prevent complications, and plan for safe removal, making it the correct action.
Choice D reason: Administering a sedative to maintain calm behavior is inappropriate without a current medical order or ongoing aggression. Sedatives carry risks like oversedation or respiratory depression. Monitoring the client’s behavior is the priority to determine if restraints can be safely discontinued, making this action unnecessary and potentially harmful.