A nurse is teaching a group of newly licensed nurses about client advocacy. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?

Rationale:

A. “I should advise a client about what I feel to be his best health care decision.": Advocacy involves supporting the client’s choices and rights, not imposing the nurse’s personal opinions. Advising based on personal beliefs undermines the client’s autonomy and is not consistent with professional advocacy.

B. "I should not advocate for a client unless he is able to ask me himself.": Client advocacy includes speaking up on behalf of clients who cannot voice their own needs, such as those who are incapacitated or vulnerable. Waiting for the client to ask would neglect the nurse’s responsibility to protect and support the client.

C. “I will intervene if there is a conflict between a client and his provider.": Advocacy involves intervening when a client’s rights, preferences, or safety are at risk, including resolving conflicts with providers. This demonstrates understanding of the nurse’s role in ensuring the client’s voice is heard and needs are met.

D. “I will inform a client that his family should help make his health care decisions.": While family input can be important, the client’s autonomy takes priority. Encouraging family decision-making over the client’s choices does not reflect proper advocacy and may compromise the client’s rights.

Rationale:

A. Establish a patent airway: Severe head trauma with active nasal bleeding raises concern for airway obstruction from blood pooling, impaired consciousness, or loss of protective reflexes. Ensuring a patent airway prevents hypoxia, which can rapidly worsen neurologic injury. Early airway control is the priority because compromised breathing poses an immediate threat to life

B. Prepare for a CT scan: A CT scan is essential for diagnosing intracranial injuries, fractures, and sources of bleeding, but the client must first have a stable airway and adequate oxygenation. Imaging cannot safely proceed until airway patency is confirmed, since deterioration during transport is a major risk.

C. Insert a peripheral IV line: IV access is necessary for fluid resuscitation and medication administration, but it is not the most urgent action when airway compromise is suspected. The risk of hypoxia outweighs the risk of delayed IV access, and airway management must occur before secondary stabilization steps. Once the airway is secured, IV access can be safely done.

D. Apply direct pressure to the nose: Direct pressure is generally used to control epistaxis, but in severe head trauma, nasal bleeding may indicate a basilar skull fracture, and pressure could worsen underlying injury or dislodge clots. Additionally, controlling bleeding is secondary to securing the airway, as blood flow can interfere with breathing.