A nurse is caring for a client who speaks a different language than the nurse. The client's partner tells the nurse that the client would like to go home against medical advice (AMA).
Which of the following actions should the nurse take?
Have the client's partner sign an AMA form
Discharge the client and notify the health care provider.
Ask the partner to reiterate the consequences of leaving AMA to the client.
Request the services of an interpreter to determine the client's wishes.
The Correct Answer is D
Effective communication with the client is crucial to understand their desires and provide appropriate care. When faced with a language barrier, it is important to use professional interpreter services to ensure accurate and clear communication. By requesting an interpreter, the nurse can obtain a clear understanding of the client's wishes and concerns regarding leaving AMA.
Without clear communication with the client, it is not appropriate to assume that the partner can make decisions on their behalf or sign an AMA form. It is important to directly ascertain the client's wishes.
Discharging the client without understanding their wishes and providing appropriate education or interventions could potentially put the client at risk. It is necessary to have a clear understanding of the client's desires before taking any action.
Asking the partner to reiterate the consequences of leaving AMA to the client: While educating the client and their partner about the consequences of leaving AMA is important, it is not sufficient in this situation. The nurse needs to directly communicate with the client to understand their wishes and concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Pain in the calf can be a potential symptom of deep vein thrombosis (DVT), which is a serious complication after surgery. Monitoring the client's pulse oximetry can help assess for signs of decreased oxygenation, which may indicate a possible clot or compromised circulation. A decrease in oxygen saturation can be an early indicator of a potential DVT-related complication, such as a pulmonary embolism. Monitoring the pulse oximetry can provide valuable information for timely intervention and management.
Instructing the client to massage the calf gently is not advisable without further assessment and evaluation. Massaging the calf can potentially dislodge a clot if one is present, leading to further complications. It is important to rule out DVT through appropriate diagnostic measures before providing specific instructions for calf massage.
Maintaining the leg in a dependent position while in bed can potentially worsen the symptoms and increase the risk of venous stasis. Elevating the affected leg, rather than maintaining it in a dependent position, can help improve venous return and reduce pain or swelling.
Applying a cold compress to the client's calf is not recommended without further assessment. Heat or cold therapy should be applied based on the underlying cause of the pain. In the case of potential DVT, applying a cold compress can increase vasoconstriction and potentially worsen the condition. It is essential to investigate the cause of the pain first and consult with the healthcare provider before initiating any specific therapies or interventions.
Correct Answer is B
Explanation
Tranylcypromine is a monoamine oxidase inhibitor (MAOI) medication used to treat depression. MAOIs inhibit the activity of the enzyme monoamine oxidase, which helps regulate the breakdown of certain neurotransmitters, including tyramine. Tyramine is typically broken down by monoamine oxidase, but when taking an MAOI, the enzyme's inhibition can lead to an excessive accumulation of tyramine in the body.
Tyramine-rich foods, such as aged cheeses, cured meats, and certain fermented or pickled foods, contain high levels of tyramine. Ingesting these foods while taking an MAOI can lead to a sudden release of stored norepinephrine, causing a hypertensive crisis.
Hypertension is a potentially serious adverse effect of MAOI therapy combined with tyramine-rich food ingestion. Symptoms of a hypertensive crisis can include severe headache, palpitations, chest pain, sweating, blurred vision, and in severe cases, it can lead to stroke or other cardiovascular complications.
Hematuria refers to the presence of blood in the urine and is not a known adverse effect of tranylcypromine or related to tyramine-rich food ingestion.
Tinnitus refers to the perception of ringing or noise in the ears and is not a known adverse effect of tranylcypromine or related to tyramine-rich food ingestion.
Hyperglycemia, or high blood sugar levels, is not a known adverse effect of tranylcypromine or related to tyramine-rich food ingestion. However, it's important to note that tranylcypromine may interact with certain diabetes medications, so it's essential to consider the client's overall medical history and potential drug interactions.
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