A nurse is caring for a client who is requesting to leave the facility against medical advice (AMA). The client states, "I am ready to go immediately." Which of the following actions should the nurse take first?
Teach the client about the potential health risks of leaving early.
Ask the client to sign a document stating they are leaving AMA.
Document the client's statement in direct quotes in the medical record.
Complete an incident report detailing the client scenario.
The Correct Answer is A
A. Teach the client about the potential health risks of leaving early: The first action the nurse should take is to inform the client about the potential health risks associated with leaving the facility against medical advice. Providing this information ensures that the client is fully informed about the consequences of their decision, which is essential for promoting their safety and well-being.
B. Ask the client to sign a document stating they are leaving AMA: While obtaining a signed document is necessary, it should occur after the client has been informed about the risks involved in leaving. The nurse should first ensure the client understands the implications of their decision.
C. Document the client's statement in direct quotes in the medical record: Documentation is important but should not be the first action taken. The nurse must first address the client’s immediate request and provide information regarding potential health risks before focusing on documentation.
D. Complete an incident report detailing the client scenario: Completing an incident report may be necessary later, but the priority should be to address the client’s safety and ensure they are making an informed decision about leaving the facility. The nurse should first engage with the client regarding their choice and the associated risks.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Red tag, life-threatening injury requiring immediate intervention: Reserved for clients with compromised airway, severe hemorrhage, or life-threatening injuries requiring immediate treatment. This client is stable, alert, and has no signs of life-threatening conditions.
B. Yellow tag, serious injury requiring delayed but urgent treatment: Applied to clients with significant but non-life-threatening injuries that require medical attention. The client has a large laceration with bleeding and is unable to walk but remains hemodynamically stable, making this the most appropriate classification.
C. Green tag, minor injury requiring minimal treatment: Used for ambulatory clients with minor injuries. The client's inability to walk due to a wound requiring further care excludes them from this category.
D. Black tag, non-survivable injury with expected poor outcome: Assigned to clients with fatal injuries or no signs of life. The client remains alert, oriented, and hemodynamically stable, so this classification is not appropriate.
Correct Answer is C
Explanation
A. Loud volume of the television set. While a loud television may indicate hearing impairment, it does not pose an immediate safety risk. The nurse should assess the client’s hearing and provide recommendations if needed, but addressing environmental hazards that increase the risk of falls takes priority.
B. Wall-to-wall carpet in the living room. Unlike loose rugs, wall-to-wall carpeting reduces the risk of tripping and slipping. It provides better traction for walking, making it a safer flooring option for older adults compared to hard surfaces or throw rugs.
C. Low chairs without armrests. Low chairs make it difficult for older adults to stand up, increasing the risk of falls. The absence of armrests further reduces stability and support when rising from a seated position. Recommending higher chairs with armrests can enhance mobility and prevent injuries.
D. Use of indirect lighting. Soft, indirect lighting can help reduce glare and improve comfort, but it may not necessarily create safety concerns. However, inadequate lighting in critical areas, such as hallways or staircases, should be assessed to prevent falls.
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