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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Provide the client with periods of alone time for reflection on their behavior: While reflection can be helpful, unsupervised alone time may increase the risk of relapse in clients with alcohol use disorder and does not actively promote self-control.
B. Discuss strategies with the client to reduce alcohol consumption gradually: Gradual reduction is not always safe due to the risk of withdrawal complications. Abstinence under supervision is the recommended approach for alcohol use disorder.
C. Have the client's partner assume responsibility for monitoring the client's alcohol intake: Delegating responsibility to a family member undermines the client’s autonomy and does not foster personal self-control or coping skills.
D. Give positive feedback to the client for using adaptive coping strategies: Reinforcing the use of healthy coping mechanisms encourages self-control, builds confidence, and promotes continued use of adaptive strategies to manage stress without relying on alcohol.
Correct Answer is A
Explanation
A. A client who is taking warfarin and has started to breastfeed: Warfarin passes into breast milk in very small amounts and is generally considered compatible with breastfeeding. However, the infant’s coagulation status should be monitored, and follow-up with the healthcare provider is appropriate to ensure safety.
B. A client who is taking bumetanide and reports an increase in urinary frequency: Increased urination is an expected pharmacologic effect of loop diuretics like bumetanide. This finding does not require follow-up unless accompanied by other concerning symptoms.
C. A client who received a Mantoux test 48 hr ago and has an induration: A positive Mantoux test requires interpretation by a healthcare provider, but the presence of induration alone is a normal finding that triggers standard follow-up for tuberculosis screening.
D. A client who is scheduled for a colonoscopy and is taking sodium phosphate: Sodium phosphate is commonly used as a bowel prep for colonoscopy. As long as the client follows the prescribed instructions and has no contraindications, this does not require additional follow-up.
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