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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Naxlex Comprehensive Predictor Exams

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C","dropdown-group-3":"D"}

Explanation

Short-term memory loss: While some degree of memory loss can be a normal part of aging, significant short-term memory loss in the context of elder mistreatment can indicate neglect or psychological abuse. It might reflect isolation or a lack of proper mental stimulation and care.
Pressure injuries: These are clear indicators of neglect. Pressure injuries, such as bedsores, occur when a person is not moved or repositioned regularly. They can suggest that the caregiver is not providing adequate care or attention to the client's physical needs.
Malnutrition: This is a strong sign of neglect. Malnutrition, evidenced by loss of subcutaneous fat and low body weight, indicates that the client is not receiving adequate nutrition. This could be due to neglect in providing food or a lack of attention to dietary needs, which is a form of mistreatment.

A. Measure the respiratory rate B. Palpate the abdomen C. Check the airway for patency D. Feel for a pulse E. Stabilize the cervical spine F. Call for an x-ray

Correct Answer is ["C","E"]

Explanation

A. Measure the respiratory rate

While important, measuring the respiratory rate is not the first priority in the primary survey of trauma assessment.
B. Palpate the abdomen

Palpating the abdomen is part of the secondary survey in trauma care, which comes after the primary survey and initial stabilization.
C. Check the airway for patency

The first step in the primary survey (ABCDE approach) is to check the airway to ensure it is patent. If the airway is not clear, the patient cannot breathe, and immediate intervention is needed.
D. Feel for a pulse

While checking circulation (which includes feeling for a pulse) is important, it comes after ensuring the airway and cervical spine are addressed.
E. Stabilize the cervical spine

In trauma patients, particularly those with falls or other significant mechanisms of injury, stabilizing the cervical spine is crucial to prevent potential spinal cord injury.
F. Call for an x-ray

Ordering imaging studies is important but is not part of the initial primary survey, which focuses on immediate life-threatening conditions.

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Naxlex Comprehensive Predictor Exams

Exhibits The nurse reviews the findings in the history and physical. Select from Word Choices to complete the sentence. The nurse recognizes that dropdown ,dropdown and dropdown are findings consistent with elder mistreatment.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C","dropdown-group-3":"D"}

Explanation

The client is a 26-year-old female who fell from an apartment balcony. She was transported to the hospital via ambulance. The client enters the emergency room on a stretcher and is met in the trauma bay by the nurse. For the primary survey, what 2 things should the nurse do first?

Correct Answer is ["C","E"]

Explanation

The nurse is caring for a client with heart failure. Which of these prescribed medications places the client at risk for cardiogenic shock?

The nurse plans to collect a 24-hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client?

The nurse is caring for a client with the sexually transmitted infection (STI) genital herpes. The client reports having sex with multiple partners. Which response should the nurse provide?

Which intervention is most important for the nurse to include in the plan of care for a client who is 12 hours post-thyroidectomy?

The nurse is teaching a primigravida about preeclampsia. What finding(s) are indicators of preeclampsia and should be reported to the healthcare provider? Select all that apply.

The nurse is teaching a group of women about osteoporosis and exercise. The nurse should emphasize the need for which type of regular activity?

The nurse is caring for a client with decompensated liver disease who is experiencing fever, chills, and abdominal tenderness. Following a paracentesis, the nurse receives laboratory results. Exhibits After notifying the healthcare provider, which action should the nurse take next?