A nurse is caring for a client who is scheduled for outpatient surgery. Which of the following actions should the nurse take to verify the client gave informed consent?

Choice A rationale:

The child having red fissures at the corners of the mouth is not the priority finding. While this could indicate a nutritional deficiency, such as vitamin B2 (riboflavin) deficiency, the presence of bruises on the child's legs raises more immediate concerns related to potential physical abuse or safety issues.

Choice B rationale:

The child having several small bruises on both legs is the priority finding. Bruising on a school-age child could indicate physical abuse or an unsafe living environment. Ensuring the child's safety and well-being takes precedence over other findings. Assessing the nature, pattern, and explanation for the bruises is crucial.

Choice C rationale:

The child sleeping for about 13 hours each night is not the priority finding in this scenario. While sleep patterns are important, the potential for physical abuse and safety concerns associated with the bruises takes precedence.

Choice D rationale:

The child not regularly attending school is a concern, but it is not the priority finding when compared to the possibility of physical abuse indicated by the bruises. Both issues need to be addressed, but ensuring the child's immediate safety is the primary focus.

Choice A rationale:

A client who is scheduled for a tubal ligation in 2 hr and is crying. Rationale: While the emotional well-being of this client is important, the absence of pulse in the right foot of the client in choice B indicates a potentially critical vascular issue that requires immediate attention.

Choice B rationale:

A client who has peripheral vascular disease and has an absent pulse in the right foot. Rationale: The correct choice. An absent pulse in a client with peripheral vascular disease suggests compromised blood flow and potential tissue ischemia. This is a critical situation that requires urgent intervention to prevent further complications.

Choice C rationale:

A client who has type 1 diabetes mellitus and needs the first dressing change for an ulcer. Rationale: While dressing changes are important, they are not as time-sensitive as addressing compromised blood flow and potential tissue damage seen in choice B.

Choice D rationale:

A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary temperature of 38°C (100.4°F). Rationale: Although an elevated temperature can be concerning, the absence of a pulse in a peripheral vascular disease client (choice B) takes precedence as it suggests a more immediate threat to the client's limb and overall health.