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. Deflate the cuff faster when repeating the BP measurement. B. Request a prescription for an antihypertensive medication. C. Use a narrower cuff to repeat the BP measurement. D. Measure the client’s BP in the other arm.

Correct Answer is D

Explanation

It's common practice to check blood pressure in both arms when there is a significant discrepancy in blood pressure readings between the arms. This discrepancy could be due to factors like arterial blockages or other conditions. By measuring the blood pressure in the other arm, the nurse can confirm whether the high blood pressure is consistent on both sides or if there was an issue with the initial measurement. This step helps provide a more accurate assessment of the client's blood pressure.

- The other options are not appropriate at this stage:

Deflating the cuff faster may not resolve the issue and could lead to inaccurate measurements.

Requesting a prescription for an antihypertensive medication should only be done after confirming the blood pressure is consistently elevated and under the direction of a healthcare provider.

Using a narrower cuff is not indicated in this situation. It's more important to assess the other arm's blood pressure to identify any discrepancies.

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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

Explanation

A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client’s BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client’s BP is 176/96 mm Hg. Which of the following actions should the nurse take?

Correct Answer is D

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?