A nurse asks a client with cirrhosis to write his/her name on a piece of paper each day. A student asks why the nurse does this. The best response by the nurse is that
a. "If the client can't write his/her name, it means the client is very confused."
b. "Part of the mini-mental exam and we assess this on all clients."
c. "The physician left orders for this but I don't know why we are doing it."
d. "This is an important safety assessment for the client with cirrhosis."
D
An important consideration for clients with cirrhosis is the development of encephalopathy and their resulting safety needs. Safety is a priority in health care. Deterioration of handwriting is an early, subtle sign of impending decrease in level of consciousness. If the nurse assesses a subtle change in level of consciousness, the nurse can implement safety precautions. Option c is the poorest choice; if the nurse does not know why she/he is doing something, the nurse needs to find out. Nurses should not just blindly follow orders without understanding the rationale.
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