A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement.
The nurse enters the client’s room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?

Tell the client that the surgeon will prescribe restraints if they try to leave.

Explain to the client that they cannot leave until the surgeon discharges them.

Have the client sign an against medical advice form.

Administer a sedative medication to the client.

Answer and Explanation

The Correct Answer is B

The correct answer is choice B: Explain to the client that they cannot leave until the surgeon discharges them.

Choice B rationale: The nurse should explain the importance of following the surgeon's orders and the potential consequences of leaving before being officially discharged. This approach provides patient education and promotes collaboration between the client and the health care team. It also ensures the client understands that leaving without proper discharge could lead to complications or inadequate recovery.

Choice A rationale: Threatening the client with restraints is not an appropriate action, as it may cause undue stress and escalate the situation. Restraints should only be used as a last resort in cases where the client poses an immediate risk of harm to themselves or others.

Choice C rationale: While having the client sign an against medical advice (AMA) form might be appropriate if the client insists on leaving, the nurse should first attempt to educate the client on the importance of following the surgeon's orders and collaborate with the client to resolve any concerns or issues leading to their desire to leave.

Choice D rationale: Administering a sedative medication is not an appropriate action in this situation. Sedation should only be used when medically necessary and not as a means to control a client's behavior or decisions.

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Correct Answer is D

Explanation

The correct answer is choice D. Unequal height of the shoulders.

This is because scoliosis is a condition characterized by sideways curvature of the spine that can cause asymmetry of the shoulders, shoulder blades, and hips.

A scoliosis screening is a test that checks for this asymmetry by having the child bend forward from the waist and looking for any prominence of the rib cage or the spine.

Choice A is wrong because expansion of the upper intercostal spaces is not a sign of scoliosis, but rather a sign of hyperinflation of the lungs due to conditions such as asthma or emphysema.

Choice B is wrong because increased convex curve of the cervical spine is not a sign of scoliosis, but rather a sign of kyphosis, which is an excessive outward curvature of the upper spine.

Choice C is wrong because increased concave curve of the thoracic spine is not a sign of scoliosis, but rather a sign of lordosis, which is an excessive inward curvature of the lower spine.

A. “I will speak with your provider on your behalf.”. B. “I will do my best to fulfill my promises to you.”. C. “I will keep your personal information private.”. D. “I will let you make decisions about your health care.”.

Correct Answer is A

Explanation

The correct answer is choice A: "I will speak with your provider on your behalf."

Choice A rationale: The principle of advocacy in nursing involves supporting and speaking up for clients to ensure their rights, needs, and preferences are respected. By offering to speak with the provider on the client's behalf, the nurse demonstrates advocacy by actively working to represent the client's interests and facilitate communication between the client and the health care team.

Choice B rationale: While promising to fulfill commitments is an aspect of maintaining professional integrity, it does not directly demonstrate advocacy. Advocacy is more about actively supporting the client's rights and needs rather than personal dedication to fulfilling promises.

Choice C rationale: Maintaining the privacy and confidentiality of client information is essential in nursing practice, but it is not specifically related to advocacy. Privacy is a separate ethical principle that focuses on protecting the client's personal information and upholding their right to privacy.

Choice D rationale: Encouraging clients to make decisions about their health care is important for promoting autonomy. However, advocacy involves actively supporting the client's decisions and ensuring their rights are respected, rather than simply allowing them to make decisions.

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A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement. The nurse enters the client’s room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with scoliosis screenings for students at a public school. Which of the following findings should the nurse recognize as an indication of scoliosis?

Correct Answer is D

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Correct Answer is A

Explanation

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A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement.
The nurse enters the client’s room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?