The nurse is caring for a client with decreased energy who needs to get up to prevent the development of pressure ulcers. The client is unable to ambulate and wants to be alone. The nurse would:
1. Use knowledge about the client to find a way to gain compliance.
2. Accede to the client's request to be left alone.
3. Notify the physician of the client's noncompliance.
4. Proceed to get help to get the client out of bed.
1. Use knowledge about the client to find a way to gain compliance.
Rationale:
The nurse would use knowledge and creativity to think critically about getting the client to cooperate with the medical regimen. For example, the nurse could revise the plan from standing to frequent position changes or consider back massages. It is not an option to leave the client alone and not address some method of ensuring intact skin. The compliance of the client rests with the nurse, not the physician. It would not be a good idea to force the client against the client's will; the nurse would use critical thinking to find another way to meet the goal.
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