A nurse is assessing a client who has been taking simvastatin to treat hyperlipidemia. Which statement made by the client describes an adverse effect of the medication that should be reported to the provider immediately?

Choice A Reason
Intervening when a client attempts self-injury may be necessary to ensure the client's immediate safety. However, this action does not primarily implement the ethical principle of autonomy. Autonomy involves respecting the client's right to make their own decisions, including the right to refuse treatment. In cases of self-harm, the nurse must balance the ethical principles of autonomy and nonmaleficence (the duty to do no harm)

Choice B Reason
Suggesting restrictions for clients who were fighting might be a measure to maintain safety within the unit. However, this suggestion does not uphold the principle of autonomy, as it involves limiting the clients' freedom and choices. The ethical principle of autonomy emphasizes the clients' right to make independent choices and to control their own actions.

Choice C Reason
Staying with a client who is experiencing a high level of anxiety is a supportive action that can be therapeutic. While it demonstrates care and may provide comfort, it does not directly implement the principle of autonomy. Autonomy is about the capacity to make informed and voluntary decisions, and while support is important, it does not equate to enabling decision-making.

Choice D Reason
Exploring alternative solutions with a client and allowing them to choose an option embodies the ethical principle of autonomy. This approach respects the client's right to be involved in their own care and to make decisions based on their values and beliefs. It empowers the client to have control over their treatment and respects their capacity for self-determination.

In psychiatric nursing, respecting autonomy means acknowledging the client's right to make choices about their care and treatment. It involves providing all necessary information and supporting the client in making informed decisions. By exploring options and allowing the client to choose, the nurse facilitates autonomy and supports the client's right to direct their own care.

Choice a reason:

A cream to soothe itching may be used if the client is experiencing pruritus, which can sometimes accompany biliary issues due to bile salts in the skin. However, pruritus is not a direct symptom of biliary colic, which is characterized primarily by pain.

Choice b reason:

Pain medication is the appropriate treatment for biliary colic. Biliary colic is caused by the temporary blockage of the bile duct by a gallstone, leading to intense pain in the upper right abdomen or the center of the abdomen. Pain relief is typically achieved with anti-inflammatory drugs or antispasmodics, and in some cases, opioids may be necessary.

Choice c reason:

An antibiotic would be prescribed if there was an infection, such as cholecystitis or cholangitis. Biliary colic itself does not necessarily indicate an infection unless accompanied by other symptoms such as fever or elevated white blood cell count.

Choice d reason:

A laxative is not typically used to treat biliary colic. While laxatives can help relieve constipation, biliary colic is a result of gallstones obstructing the bile duct, not bowel movement issues.