Which data is cause for immediate intervention for a client after a right shoulder replacement?

Choice A Reason
Intervening when a client attempts self-injury may be necessary to ensure the client's immediate safety. However, this action does not primarily implement the ethical principle of autonomy. Autonomy involves respecting the client's right to make their own decisions, including the right to refuse treatment. In cases of self-harm, the nurse must balance the ethical principles of autonomy and nonmaleficence (the duty to do no harm)

Choice B Reason
Suggesting restrictions for clients who were fighting might be a measure to maintain safety within the unit. However, this suggestion does not uphold the principle of autonomy, as it involves limiting the clients' freedom and choices. The ethical principle of autonomy emphasizes the clients' right to make independent choices and to control their own actions.

Choice C Reason
Staying with a client who is experiencing a high level of anxiety is a supportive action that can be therapeutic. While it demonstrates care and may provide comfort, it does not directly implement the principle of autonomy. Autonomy is about the capacity to make informed and voluntary decisions, and while support is important, it does not equate to enabling decision-making.

Choice D Reason
Exploring alternative solutions with a client and allowing them to choose an option embodies the ethical principle of autonomy. This approach respects the client's right to be involved in their own care and to make decisions based on their values and beliefs. It empowers the client to have control over their treatment and respects their capacity for self-determination.

In psychiatric nursing, respecting autonomy means acknowledging the client's right to make choices about their care and treatment. It involves providing all necessary information and supporting the client in making informed decisions. By exploring options and allowing the client to choose, the nurse facilitates autonomy and supports the client's right to direct their own care.

Choice A Reason
Hyperreflexia refers to an overactive or overresponsive reflexes, which is a neurological condition and not directly related to the behaviors described. It is typically seen in conditions affecting the central nervous system and is not characterized by the inability to wait turns or interrupting conversations.

Choice B Reason
Defiance implies a conscious choice to resist authority or rules, which may not necessarily be the case here. While children with behavioral issues may exhibit defiant behaviors, the symptoms described are more indicative of a lack of impulse control rather than a deliberate choice to defy.

Choice C Reason
Inattention is a component of several behavioral and cognitive disorders, including ADHD. However, the behaviors described—blurting out answers, inability to wait for turns, and interrupting others—are more specifically associated with impulsivity rather than inattention alone.

Choice D Reason
Impulsivity is the tendency to act on a whim, displaying behavior characterized by little or no forethought, reflection, or consideration of the consequences. The behaviors described—such as blurting out answers and interrupting others—are classic signs of impulsivity, which is often seen in conditions like ADHD.