Level: Foundational
Difficulty: Easy
Subtopic: Autonomy and informed consent
NCLEX: A 64-year-old client on a medical-surgical unit is being evaluated for nursing care related to autonomy and infor…
Ethics, legal nursing, delegation, prioritization Management of Care
Case Study
A 64-year-old client on a medical-surgical unit is being evaluated for nursing care related to autonomy and informed consent. Assessment data include family requests lab results by phone without verified authorization. Which intervention best reduces the client's risk of complications?
Question
A. Restrict all movement without individualized assessment.
B. Delay teaching until the day of discharge only.
C. Ignore small changes until they become severe.
D. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
B. Delay teaching until the day of discharge only.
C. Ignore small changes until they become severe.
D. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
Rationale
Correct answer: D. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
Rationale: Risk reduction focuses on early identification, prevention, teaching, and reassessment rather than unnecessary restriction or delay.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Risk reduction focuses on early identification, prevention, teaching, and reassessment rather than unnecessary restriction or delay.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.