A nurse is caring for a client on a medical-surgical unit who is attempting to leave the facility.
Which of the following actions should the nurse take?
Notify the facility's security department.
Call the client's family.
Make sure the client understands that he is leaving against medical advice.
Insist that the client exit the hospital via a wheelchair.
The Correct Answer is C
Choice A rationale
While security notification might be necessary if the client becomes disruptive or poses a danger to themselves or others, the initial and most crucial step is to ensure the client is fully informed about the potential health risks and consequences of leaving without a formal discharge (Against Medical Advice or AMA).
Choice B rationale
Calling the client's family may be appropriate after fully informing the client and assessing their capacity, but it does not replace the primary nursing responsibility to ensure informed refusal. The patient has a right to autonomy, and the first step is to ensure that right is exercised with full understanding of the decision.
Choice C rationale
The nurse's primary responsibility is to ensure the client has the mental capacity to make the decision and is fully informed of the risks associated with discontinuing treatment prematurely. Documenting the client's understanding of leaving Against Medical Advice (AMA) is a critical legal and ethical safeguard.
Choice D rationale
While using a wheelchair is a safety measure often employed for hospital discharge, it is not mandatory for a client leaving AMA who is deemed competent and physically able to walk. Insisting on it infringes on the client's autonomy and is not the priority action when a client is choosing to leave AMA.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
The pain threshold, the minimum intensity at which a stimulus is perceived as painful, is fundamentally subjective and varies significantly among individuals. This biological variability is due to differences in nociceptor sensitivity, genetic factors influencing neurotransmitter levels (like endorphins), and individual processing within the central nervous system. Therefore, stating it's the same for all post-surgical patients disregards these crucial physiological and neurobiological differences.
Choice B rationale
A higher pain threshold implies a greater stimulus intensity is needed for pain perception. While anticipatory anxiety related to biopsy results can acutely raise stress hormones, which might transiently elevate the threshold through endogenous opioid release and the descending inhibitory pain pathway activation, sustained or severe stress is often correlated with a lowering of the threshold due to central sensitization and hyperalgesia, thus this is not a universal principle.
Choice C rationale
Difficulty sleeping, leading to fatigue and sleep deprivation, is a known factor that consistently lowers the pain threshold and tolerance. Sleep is vital for restoring neuromodulatory balance; its disruption increases pro-inflammatory cytokines, enhancing the excitability of dorsal horn neurons (central sensitization), and thus decreasing the stimulus required to elicit pain perception (hyperalgesia). Therefore, the threshold would likely be lower, not higher.
Choice D rationale
Anxiety and fear significantly activate the sympathetic nervous system and trigger the release of various stress mediators (e.g., substance P, glutamate) in the central nervous system. This neuromodulation often results in hyperalgesia and allodynia through central sensitization, amplifying pain signal transmission and perception, thereby lowering the pain threshold and pain tolerance.
Correct Answer is ["50"]
Explanation
Step 1 is to calculate the total time for the infusion in minutes:. 8 hr × 60 min/hr = 480 min.
Step 2 is to calculate the gtt/min using the formula Volume in mL÷Time in min/Drop factor. (400 mL ÷ 480 min) × 60 gtt/mL.
Step 3 is to calculate the intermediate value of the mL/min:. 400 mL ÷ 480 min = 0.8333 mL/min.
Step 4 is to calculate the gtt/min:. 0.8333 mL/min × 60 gtt/mL = 49.998 gtt/min.
Step 5 is to round the answer to the nearest whole number:. 49.998 gtt/min rounds to 50 gtt/min. The final calculated answer is 50 gtt/min.
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