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 A
Explanation
Rationale:
A. The child believes the person will return: Preschoolers view death as temporary and reversible due to their developmental stage and limited understanding of permanence. Magical thinking often leads them to expect the deceased person to come back.
B. The child focuses on his own mortality: This is more typical of older school-age children or adolescents, who have a more developed understanding of death’s permanence and may begin to consider their own vulnerability.
C. The child refuses to talk about the death: Avoidance can occur at any age, but it is not the primary expected response in preschoolers. At this stage, they may ask repetitive questions or make statements that suggest misunderstanding, rather than complete refusal to talk.
D. The child expresses curiosity about the death process: Curiosity about death’s physical aspects is more common in school-age children, who have greater cognitive ability to think concretely about biological processes.
Correct Answer is C
Explanation
A. Assist the family to establish a daily routine: Establishing routines can provide structure, but it is more effective after the nurse has assessed the family’s current functioning and needs following the loss.
B. Refer the family to a grief support group: Referral to support groups is beneficial, but it is not the initial step. Understanding the family’s dynamics and coping capacity should precede external referrals.
C. Determine the roles of individual family members: Assessing each member’s role and function helps the nurse understand how the family is coping and identifies areas of strength and need. This assessment guides appropriate interventions and prioritizes support.
D. Encourage the family to assign specific tasks to individual family members: Assigning tasks is part of restoring structure, but it should follow an assessment of roles and capabilities to ensure tasks are appropriate and achievable.
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