A nurse on a medical-surgical unit is caring for a client who states that she plans to leave the facility against medical advice. For which of the following actions by the nurse should the charge nurse intervene?
Asks the client what her plans are for follow-up care
Asks the client to sign a form releasing the hospital from legal responsibility
Shows the client her abnormal laboratory results
Asks security to detain the client until the provider is notified
None
None
The Correct Answer is D
Rationale:
A. Asks the client what her plans are for follow-up care: This is an appropriate action that demonstrates concern for the client’s continuity of care and safety, even if she decides to leave against medical advice.
B. Asks the client to sign a form releasing the hospital from legal responsibility: This is standard practice when a client leaves against medical advice, as it documents that the client was informed of potential risks and chose to leave voluntarily. This action is appropriate and does not require the charge nurse to intervene.
C. Shows the client her abnormal laboratory results: Providing relevant medical information is appropriate to help the client make an informed decision about her care before leaving the facility.
D. Asks security to detain the client until the provider is notified: Clients have the legal right to leave a healthcare facility unless they are under specific legal or mental health holds. Detaining a competent adult against their will is unlawful and violates patient rights hence requiring intervention by the charge nurse.
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Related Questions
Correct Answer is B
Explanation
Rationale:
A. "I recommend that you take this medication as prescribed.": This response dismisses the client’s concern and does not address the possibility of a medication error. It can also undermine trust and ignores the need for verification before administration.
B. "I will call the pharmacist now to check on this medication.": This is the most appropriate response because it prioritizes client safety by verifying the medication before administration. It also acknowledges the client’s concern and involves a qualified resource for confirmation.
C. "Did the doctor discuss with you that there was a change in this medication?": While this could provide insight into changes in therapy, it delays immediate verification and does not address the need to confirm the medication’s accuracy before giving it.
D. "Do you know why this medication is being prescribed for you?": This may promote client education, but it does not address the immediate safety concern or the need to verify the medication before administration.
Correct Answer is D,B,E,C,A
Explanation
Rationale:
A. Record information about the home visit according to agency policy: Documentation is performed at the end of the visit to ensure that all observations, interventions, and plans are accurately recorded in the client’s record for continuity of care.
B. Contact the family to determine availability and readiness to make an appointment: Before visiting, the nurse should coordinate with the family to schedule a convenient time, ensuring that they are prepared for the assessment and intervention process.
C. Discuss plans for future visits with the family: After assessing the client and identifying needs, the nurse should collaborate with the family to plan ongoing visits and care strategies that align with their goals and availability.
D. Clarify the reason for the referral with the provider's office: This is the first step to ensure the nurse understands the purpose of the referral, specific concerns, and any important background information before contacting the family.
E. Identify family needs and interventions using the nursing process: During the visit, the nurse collects data, assesses needs, and develops appropriate interventions, forming the foundation for the care plan moving forward.
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