A nurse is caring for a client on a medical-surgical unit who is attempting to leave the facility. Which of the following actions should the nurse take?

Choice A rationale While security notification might be necessary if the client becomes disruptive or poses a danger to themselves or others, the initial and most crucial step is to ensure the client is fully informed about the potential health risks and consequences of leaving without a formal discharge (Against Medical Advice or AMA). Choice B rationale Calling the client's family may be appropriate after fully informing the client and assessing their capacity, but it does not replace the primary nursing responsibility to ensure informed refusal. The patient has a right to autonomy, and the first step is to ensure that right is exercised with full understanding of the decision. Choice C rationale The nurse's primary responsibility is to ensure the client has the mental capacity to make the decision and is fully informed of the risks associated with discontinuing treatment prematurely. Documenting the client's understanding of leaving Against Medical Advice (AMA) is a critical legal and ethical safeguard. Choice D rationale While using a wheelchair is a safety measure often employed for hospital discharge, it is not mandatory for a client leaving AMA who is deemed competent and physically able to walk. Insisting on it infringes on the client's autonomy and is not the priority action when a client is choosing to leave AMA.