A client on the cardiac telemetry unit unexpectedly begins manifesting ventricular fibrillation and the advanced cardiac life support (ACLS) team defibrillates the client, restoring a normal sinus rhythm. Later in the day, a family member questions why the code was called, telling the nurse that the client has a living will. How should the nurse respond?

Schedule a client and family conference to review the plan of care.

Seek clarification of the type of advance directive the client has.

Check the client's arm for a "Do Not Resuscitate" (DNR) bracelet.

Explain that living wills cannot be followed by emergency personnel.

Answer and Explanation

The Correct Answer is B

A.   While scheduling a client and family conference may be necessary to discuss the plan of care, the immediate concern is to determine the type of advance directive the client has and whether it includes preferences regarding resuscitation.
B.   This is the most appropriate action because it addresses the family member's concern and ensures that the client's wishes regarding resuscitation are understood and followed.
C.   While checking for a DNR bracelet is important, it does not address the family member's question about why the code was called despite the client having a living will.
D.   This statement is incorrect. Living wills can guide decision-making regarding end-of-life care, including resuscitation, depending on the legal requirements and documentation in place.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}

Explanation

A. Functional Improvement: This is crucial to assess because it indicates the effectiveness of the interventions implemented, such as physical and occupational therapy, and the overall progress of the client in regaining independence in activities of daily living. Tracking functional improvements helps determine if the client's physical abilities, mobility, and self- care skills are improving over time, which is essential for their overall well-being and quality of life.

B. Psychological Assessment: This aspect is important to evaluate because it helps gauge the client's mental and emotional well-being. Elderly individuals who are subjected to neglect or mistreatment, as in this case, may experience psychological distress, such as depression, anxiety, or feelings of helplessness. Monitoring the client's psychological status allows the nurse to identify any signs of emotional distress or trauma resulting from their situation, enabling appropriate interventions to support their mental health and emotional stability.

Additionally, assessing the caregiver's psychological well-being is also crucial as they may experience stress, burnout, or emotional strain from the caregiving responsibilities, which can impact the quality of care provided to the client.

A. Self-care deficit relative to motor disturbance. B. Risk for aspiration relative to muscle weakness. C. Risk for constipation relative to immobility. D. Impaired physical mobility relative to muscle rigidity.

Correct Answer is B

Explanation

A. Self-care deficit relative to motor disturbance. While self-care deficit is a concern for clients with Parkinson's disease due to motor disturbances, the highest priority is addressing the risk for aspiration to prevent potential life-threatening complications such as aspiration pneumonia.
B. Risk for aspiration relative to muscle weakness. Parkinson's disease can cause muscle weakness and impaired swallowing function, leading to an increased risk of aspiration.
Aspiration pneumonia is a severe complication that requires immediate attention, making this the highest priority nursing problem.
C. Risk for constipation relative to immobility. Constipation is a common problem in Parkinson's disease due to immobility and medication side effects. While constipation should be addressed, it is not as immediately life-threatening as the risk for aspiration.
D. Impaired physical mobility relative to muscle rigidity. Impaired physical mobility is a significant concern in Parkinson's disease, but muscle rigidity does not necessarily pose an
immediate risk of aspiration. Addressing impaired mobility is important for maintaining overall function and quality of life but may not be the highest priority in this scenario.

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Naxlex Comprehensive Predictor Exams

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}

Explanation

In formulating the nursing care plan for a client diagnosed with Parkinson's disease, which nursing problem has the highest priority?

Correct Answer is B

Explanation

Exhibits For each statement, click to specify whether the statement is consistent with iron deficiency anemia, vitamin B12 deficient anemia, or folic acid deficient anemia. Each row must have at least one, but may have more than one, response option selected.

The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized older client with an indwelling urinary catheter every two hours. Which additional action should the nurse instruct the UAP to take each time the client is turned?

Exhibits Which 2 orders should the nurse complete first?

A client with diabetic peripheral neuropathy has been taking pregabalin for 4 days. Which finding indicates to the nurse that the medication is effective?

A client with schizophrenia reports auditory hallucinations when admitted to the hospital. Which question is most important for the nurse to include in the assessment of this client?

The nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. Which information is most important for the nurse to include?

The nurse is collecting a heelstick blood specimen for a neonatal screen, which includes thyroxine (T4) and thyroid stimulating hormone (TSH) levels, prior to the discharge of a 2-day- old client. When the parents ask why these tests are being conducted, which explanation should the nurse provide?