An unresponsive male victim of a diving accident is brought to the emergency department where it is determined that immediate surgery is required to save his life.

The client is accompanied by a close friend, but no family members are available.

Which action should the nurse take first?

The correct answer is choicea. Carry on with surgical preparation of the client without a signed informed consent.

Choice A rationale:

In emergency situations where immediate surgery is required to save a patient’s life and no family members are available, the doctrine of presumed consent applies.This means that healthcare providers can proceed with necessary treatment without a signed informed consent to prevent serious harm or death.

Choice B rationale:

Asking the man’s friend to sign the informed consent is not appropriate because friends are not legally authorized to provide consent for medical procedures unless they have legal documentation proving their authority.

Choice C rationale:

Notifying the unit manager for an emergency court order would delay the necessary surgery, which could be detrimental to the patient’s health. In emergencies, immediate action is required, and waiting for a court order is not feasible.

Choice D rationale:

Continuing to provide life support while searching for a guardian would also delay the necessary surgery. In life-threatening situations, immediate surgical intervention is prioritized over finding a legal guardian.

Choice A rationale:

Substituting natural fruit juices for carbonated drinks may be a beneficial dietary change, but it does not address the client's immediate issue of severe pain and inability to bear weight on the right ankle. This choice does not directly address the client's current problem and should not be the priority instruction in discharge teaching.

Choice B rationale:

Encouraging active range of motion to limit stiffness is the most appropriate instruction in this situation. The client's inability to bear weight on the right ankle after making dietary changes may be related to musculoskeletal issues or gouty arthritis. Active range of motion exercises can help prevent stiffness and improve joint function.

Choice C rationale:

Using an electric heating pad when pain is at its worst may provide some comfort, but it does not address the underlying cause of the severe pain in the right ankle. It is important to address the cause of the pain rather than relying solely on symptom management.

Choice D rationale:

Avoiding the consumption of wine, beer, and coffee may be relevant for some medical conditions, but it does not directly address the client's current problem of severe ankle pain and inability to bear weight. It is not the most immediate concern.