A nurse is caring for a client on the medical-surgical unit.
The client has been taking warfarin at home and her laboratory values reveal her INR is 3.5. The client states she is checking herself out of the hospital and refuses to wait until her provider can discuss the situation with her.
Which of the following actions should the nurse take?
Tell the client if she leaves without a written prescription for discharge, her insurance will not pay for the facility visit.
Tell the client she will not be permitted to leave the facility until she has signed the against medical advice (AMA) form.
Ask the security department to guard the room to the client's door.
Explain the risk the client faces if she leaves the facility.
The Correct Answer is D
Choice A rationale
Discussing insurance coverage is beyond the nurse's scope of practice and does not address the immediate safety concern related to the elevated INR. The nurse's primary responsibility is patient safety and education regarding potential health risks, not financial implications. The client's autonomy in making healthcare decisions is paramount.
Choice B rationale
A client cannot be legally detained in a healthcare facility against their will, assuming they are of sound mind. Requiring a signed Against Medical Advice (AMA) form is a documentation process, not a prerequisite for discharge. Detaining a competent client constitutes false imprisonment, violating their civil liberties.
Choice C rationale
Asking security to guard the room is a restrictive action that infringes upon the client's autonomy and right to leave. This approach is coercive and may escalate the situation, potentially leading to a legal and ethical dilemma. It does not prioritize patient education or safety through explanation.
Choice D rationale
Explaining the risks associated with leaving against medical advice, especially with an elevated INR, is crucial for informed decision-making. An INR of 3.5 indicates increased bleeding risk (normal range 0.8-1.2 or 2.0-3.0 for therapeutic anticoagulation). Providing this scientific information allows the client to understand potential adverse physiological events.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While monitoring clients is important, placing a client with active tuberculosis in a room within view of the nurses' station does not address the fundamental need for infection control. Tuberculosis is an airborne disease requiring specific environmental controls to prevent transmission, which this choice does not provide.
Choice B rationale
A room with air exhaust directly to the outdoor environment, often called a negative pressure room or airborne infection isolation room (AIIR), is essential for clients with active tuberculosis. This design prevents airborne mycobacteria from circulating within the healthcare facility, directing them outside to reduce the risk of transmission to others.
Choice C rationale
Placing a client with active tuberculosis in the ICU is generally unnecessary unless their clinical condition warrants critical care, such as respiratory failure. The primary concern for tuberculosis is airborne isolation, which can be achieved on a regular medical-surgical unit with appropriate room design and ventilation, not necessarily an ICU level of care.
Choice D rationale
Cohabiting a client with active tuberculosis with another nonsurgical client is highly inappropriate and unsafe. Tuberculosis is transmitted via airborne particles, and co-rooming would expose the other client to a significant risk of infection. Dedicated isolation is paramount for preventing nosocomial spread.
Correct Answer is A
Explanation
Choice A rationale
Coronary artery disease (CAD) is characterized by atherosclerosis, a process where plaque accumulates within the arterial walls. This accumulation progressively narrows the lumen of the coronary arteries, reducing their internal diameter. This narrowing restricts blood flow, leading to insufficient delivery of oxygen and vital nutrients to the myocardial tissue, resulting in symptoms like angina, especially during increased metabolic demand.
Choice B rationale
While CAD can lead to myocardial weakening over time due to chronic ischemia or infarction, the primary initial pathology and correlation with manifestations like angina is the narrowing of the coronary arteries, not a general weakening of the heart and arteries. Poor perfusion results from the arterial narrowing, not primarily from weakening itself.
Choice C rationale
Arteries generally lose elasticity with age, becoming stiffer and less compliant, a process known as arteriosclerosis. This stiffening contributes to increased systolic blood pressure and can exacerbate the effects of atherosclerosis. However, coronary arteries do not become "more elastic" in CAD; rather, they become less elastic and narrowed due to plaque formation.
Choice D rationale
Dilation of coronary arteries with increased blood flow is the opposite of what occurs in CAD. In CAD, there is progressive narrowing and stiffening, leading to reduced blood flow. Increased pressure can result from arterial stiffening, but the primary mechanism for manifestations like angina is the insufficient blood flow due to the narrowed lumen, not dilation.
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