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 A
Explanation
A. Identify the client's current health needs: Assessing the client’s history and physical condition allows the case manager to determine immediate health needs. This step ensures that care planning is based on the client’s specific symptoms, disease progression, and required interventions. Identifying health priorities first helps guide appropriate referrals and treatment decisions.
B. Call the provider with a list of client concerns: While communicating concerns to the provider is important, it should be done after identifying the client’s specific health needs. This approach ensures that discussions with the provider are focused and relevant. Without a clear assessment of needs, the information provided may be incomplete or unstructured.
C. Compile a list of community resources for the client: Community resources can support long-term COPD management, but they should be tailored to the client’s identified needs. The case manager must first assess what resources will be beneficial. Providing resources without understanding the client’s priorities may lead to ineffective or unnecessary recommendations.
D. Refer the client to a COPD support group: Support groups can provide valuable education and emotional support, but referrals should be based on the client’s preferences and readiness. Identifying health needs is the priority before making specific referrals. Ensuring that the client is open to and will benefit from a support group enhances the effectiveness of the referral.
Correct Answer is A
Explanation
A. I should get assistance when lifting more than 35 pounds: The recommended guideline for safe lifting is to seek assistance or use mechanical aids when lifting objects heavier than 35 pounds. This helps prevent musculoskeletal injuries, particularly in healthcare settings where lifting and repositioning patients is common.
B. I will twist at my waist when moving an object: Twisting at the waist while lifting or moving objects increases the risk of back strain and injury. Proper body mechanics involve pivoting with the feet rather than twisting the torso to reduce stress on the spine and prevent injury.
C. I should hold objects 1 foot away from my body when I walk: Holding objects away from the body increases strain on the arms, shoulders, and back. Keeping objects close to the body, at waist level, helps maintain balance, reduces muscle fatigue, and minimizes the risk of injury.
D. I will roll my shoulders forward to reduce strain on my back: Rolling the shoulders forward can lead to poor posture and increased back strain. Maintaining a neutral spine, keeping the shoulders relaxed and aligned, and engaging core muscles help reduce the risk of injury when lifting or moving objects.
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