A nurse in a long-term care facility is assessing a client who has returned from an acute care facility following a brief illness. The nurse observes that the client is confused and agitated. Which of the following actions should the nurse take first?

Choice A Reason:
Stating that the facility is unable to release the records, may not be accurate. Facilities typically have processes in place for releasing medical records upon request, although they may require written authorization.
Choice B Reason:
"You must submit a written request before you can receive a copy." This statement is correct. In most healthcare facilities, patients are required to submit a written request to obtain copies of their medical records. This process ensures that proper documentation is maintained and helps protect patient confidentiality and privacy. Additionally, providing medical records without proper authorization could violate healthcare privacy laws such as HIPAA (Health Insurance Portability and Accountability Act).
Choice C Reason:
Asking about the client's intentions with the medical record, is not appropriate as it could be seen as intrusive. Patients have the right to access their medical records for various purposes, and their intentions may not be relevant to fulfilling the request.
Choice D Reason:
Agreeing to make a copy of the medical records right away, is not the correct response without proper authorization. Making copies of medical records without following established procedures could lead to legal and ethical issues.

Choice A Reason:
Telling the client that their blood alcohol level will be checked is incorrect. Threatening the client with other forms of testing may not be ethically or legally appropriate, especially if the client has refused the initial request. It's important to respect the client's autonomy and right to refuse testing.
Choice B Reason:
Informing the client that a catheter will be inserted is incorrect. Inserting a catheter against the client's will is invasive and would constitute a violation of the client's autonomy and bodily integrity. It is not an appropriate action.
Choice C Reason:
Documenting the client's refusal in their chart is correct. Documenting the client's refusal is essential for accurate record-keeping and ensures that the healthcare team is aware of the client's decision. It also helps protect the nurse and the healthcare facility in case of any legal or ethical challenges related to the client's refusal.
Choice D Reason:
Assessing the client for urinary retention is incorrect. While urinary retention may be a concern in some cases, it is not the immediate action to take when a client refuses to provide a urine sample. The priority is to respect the client's autonomy and document their refusal appropriately. If there are clinical indications or concerns about urinary retention, they can be assessed separately and addressed accordingly.