An 80-year-old client with a history of moderate dementia is brought to the emergency department by a concerned neighbor after being found wandering outdoors in freezing weather without a coat. The client is shivering, disoriented to place and time, and attempts to walk out of the treatment room, stating, "I have to go home right now to feed my dog." Which of the following is the most appropriate legal and professional action by the registered nurse (RN)?
- ADirect the unlicensed assistive personnel (UAP) to assess the client's level of orientation to determine if they can legally sign a refusal of treatment form.
- BApply physical limb restraints immediately to secure the client to the stretcher and prevent an unsafe elopement into the cold.
- Initiate continuous one-to-one observation and verbal redirection, as the client currently lacks the legal capacity to leave against medical advice.Answer
- DReport the neighbor to Adult Protective Services (APS) for elder neglect due to the client's exposure to freezing temperatures.
Answer
The nurse should initiate continuous one-to-one observation and verbal redirection to maintain safety, as the confused client lacks the capacity to leave against medical advice.
The correct action balances the client's right to autonomy with the nurse's duty of beneficence. Because the client is disoriented and lacks the capacity to understand the extreme danger of wandering in freezing weather, they cannot legally sign an against medical advice (AMA) form. The nurse must protect the client from harm using the least restrictive means possible, which is one-to-one observation and redirection.
Step-by-Step Solution
Key Concept
Clients with impaired cognition who pose an immediate danger to themselves lack the legal capacity to leave against medical advice. The nurse must protect the client using the least restrictive alternatives.