A nurse is collecting data from a child who is 1 hr postoperative following a tonsillectomy. Which of the following findings is the nurse's priority?

A. Nonmaleficence: Nonmaleficence refers to the obligation to do no harm and to avoid causing injury. While this principle is always important in healthcare, the central issue in this scenario involves respecting the client's decision-making rights rather than directly preventing harm.

B. Autonomy: Autonomy is the ethical principle that supports a client's right to make their own healthcare decisions, even if those decisions differ from the wishes of others, including family members. Respecting the 18-year-old client's choice to decline surgery honors their legal and moral right to self-determination.

C. Beneficence: Beneficence involves taking actions that promote the well-being and best interests of the client. While advocating for the surgery could be seen as promoting beneficence, the nurse’s primary ethical duty in this situation is to respect the client’s independent decision.

D. Justice: Justice is concerned with fairness and the equitable distribution of healthcare resources. Although justice is a core ethical principle, it does not directly apply to an individual’s right to refuse treatment as seen in this situation.

• Frequent headaches: Phenelzine, an MAOI, can cause hypertensive crisis, with one of the earliest signs being persistent or worsening headaches. Frequent headaches must be treated as a possible warning of dangerously elevated blood pressure and require immediate provider notification.
• Elevated blood pressure (169/91 mm Hg): The significant rise in the client's blood pressure compared to baseline indicates new-onset hypertension. This is a serious adverse effect associated with MAOIs and signals the potential development of a hypertensive crisis, which must be urgently addressed.
• Difficulty sleeping: Difficulty sleeping or insomnia is a common side effect of phenelzine and other antidepressants. Although not life-threatening, insomnia can impair recovery if untreated and should be documented and discussed with the provider to adjust management if needed.
• Feeling much better: Improvement in mood and reduced fatigue are intended therapeutic outcomes of phenelzine treatment. These findings are positive signs and do not indicate an adverse reaction that needs intervention.
• Heart rate 78/min and respiratory rate 18/min: Both values are within normal ranges and do not suggest immediate concerns related to cardiovascular or respiratory function. They should continue to be monitored but do not require urgent action.