A client who has advanced heart failure is admitted to the hospital for symptom management. The client tells the nurse that he does not want any resuscitation measures if his heart stops. Which of the following actions should the nurse take?
A) Respect the client's wishes and document them in the medical record.
B) Inform the client that he needs to have a written advance directive to refuse resuscitation.
C) Encourage the client to reconsider his decision and discuss the benefits of resuscitation.
D) Notify the health care provider and request a referral to a palliative care team.
Respect the client's wishes and document them in the medical record.
Inform the client that he needs to have a written advance directive to refuse resuscitation.
Encourage the client to reconsider his decision and discuss the benefits of resuscitation.
Notify the health care provider and request a referral to a palliative care team.
The Correct Answer is D
The nurse should notify the health care provider and request a referral to a palliative care team, which can help the client and his family explore his goals of care, preferences, values, and beliefs regarding end-of-life care. The palliative care team can also assist with completing an advance directive, which is a legal document that specifies the client's wishes for medical treatment in case he becomes unable to communicate them.
Option A is incorrect because respecting the client's wishes is not enough; the nurse should also ensure that they are communicated to the health care team and documented in an advance directive.
Option B is incorrect because although an advance directive is recommended, it is not required; the client can verbally express his wishes to his health care provider, who can then write a do-not-resuscitate (DNR) order.
Option C is incorrect because it is not appropriate for the nurse to impose her own values or opinions on the client; rather, she should respect his autonomy and support his decision.
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Related Questions
Correct Answer is A
Explanation
Palliative care is a holistic approach to care that focuses on improving the quality of life for clients with serious illnesses and their families. It addresses physical, emotional, social, and spiritual needs, and can be provided at any stage of illness, along with curative treatments.
Option B is incorrect because palliative care does not necessarily involve withdrawing treatments or medications, unless they are causing more harm than benefit.
Option C is incorrect because palliative care does not aim to cure the disease, but rather to manage the symptoms and enhance comfort.
Option D is incorrect because palliative care is not the same as hospice care, which is a specific type of palliative care for clients who have a life expectancy of six months or less and have decided to forego curative treatments.
Correct Answer is C
Explanation
The nurse should instruct the family member to call the hospice nurse first to get an order for a higher dose of morphine, if needed. The hospice nurse can assess the client's pain level, vital signs, and response to the medication, and adjust the dose accordingly.
Option A is incorrect because although respiratory rate is one of the factors to monitor when administering opioids, it is not the only one; other factors include level of consciousness, oxygen saturation, and presence of adverse effects. Moreover, the family member should not increase the dose of morphine without consulting the hospice nurse.
Option B is incorrect because although respiratory depression is a potential side effect of opioids, it is not a common cause of death in clients receiving palliative care; rather, opioids are considered safe and effective for managing pain and dyspnea in dying clients, as long as they are prescribed and administered appropriately.
Option D is incorrect because tolerance and dependence are not major concerns in clients receiving palliative care; rather, the goal is to provide adequate pain relief and comfort for the client.
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