A nurse on a postpartum unit is caring for a client.

Exhibits

For each finding, click to specify if the finding is consistent with uterine atony or infection. Each finding may support more than 1 disease process or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row. (Note: Each column must have at least 1 response option selected)

Rationale:

A. Evaluate the client's ability to help with repositioning: Assessing the client's motor function and ability to assist is essential for planning a safe and effective repositioning strategy. It helps prevent injury to both the client and staff and allows for appropriate use of equipment or assistance.

B. Reposition the client without the use of assistive devices: Clients with impaired mobility due to stroke are at increased risk for injury during movement. Assistive devices should be used as needed to ensure safe and proper repositioning.

C. Raise the side rails on both sides of the client's bed during repositioning: Raising both side rails can create a restraint-like situation and may increase fall risk. Only the side rail on the opposite side of movement should be raised for safety during repositioning.

D. Discuss the client's preferences for determining a repositioning schedule: While involving the client in care decisions is important, repositioning schedules are primarily based on clinical needs (e.g., immobility, pressure ulcer prevention), not solely on preference.

Rationale:

A. "The proxy should manage legal issues for the client." A health care proxy designated through a durable power of attorney for health care is authorized to make medical not legal decisions. Legal affairs typically require a separate legal power of attorney.

B. "The proxy can make treatment decisions if the client is under anesthesia." The health care proxy is activated when the client is unable to make decisions for themselves, including temporary incapacity such as being under general anesthesia. This ensures continuity of care and respects the client’s wishes.

C. "The proxy should make health care decisions for the client regardless of the client's ability to do so." The proxy only steps in when the client is deemed incapacitated. If the client is alert and competent, they retain the right to make all decisions about their care.

D. "The proxy can make financial decisions if the need arises." A health care proxy does not have authority over financial matters. Financial decisions are managed through a separate durable power of attorney for finances, not through a health care DPAHC.