A health care provider asks the nurse about an older adult client's durable power of attorney (POA) because consent is needed for a medically necessary invasive procedure. The client has end-stage disease, is intubated, and is on mechanical ventilation. Which steps should the nurse implement?
Assist with obtaining informed consent from the client.
Refer to the client's advance directive for a name.
Determine the client's inability to make reasonable decisions.
Use the oral trail-making test to measure cognitive function.
The Correct Answer is C
A. Assist with obtaining informed consent from the client.
Explanation: Informed consent is a critical aspect of healthcare procedures, but it requires the patient to have the capacity to understand and make decisions. In this scenario, the client is intubated and on mechanical ventilation, which might compromise their ability to communicate effectively. If the client lacks capacity, obtaining consent from the durable power of attorney (POA) is more appropriate.
B. Refer to the client's advance directive for a name.
Explanation: Advance directives, including the durable POA, provide guidance on a person's wishes for healthcare decisions when they are unable to communicate. However, the advance directive may not always specify a particular person's name for decisions related to specific medical interventions. The key consideration in this situation is to determine the current decision-making capacity and involve the appropriate decision-maker if needed.
C. Determine the client's inability to make reasonable decisions.
Explanation: This is the correct answer. In this scenario, the nurse should assess the client's capacity to make decisions. If the client lacks capacity, the durable POA can be activated to make healthcare decisions on behalf of the client. Capacity involves the ability to understand relevant information, appreciate the consequences of decisions, and communicate a choice.
D. Use the oral trail-making test to measure cognitive function.
Explanation: The oral trail-making test is a cognitive screening tool, but it may not be suitable in this critical care scenario with an intubated and mechanically ventilated patient. Moreover, the primary concern in this situation is determining the capacity to make healthcare decisions, which requires a more comprehensive evaluation than a specific cognitive function test. The focus should be on decision-making capacity rather than a cognitive assessment.
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Related Questions
Correct Answer is C
Explanation
A. This statement is not entirely accurate. While Medicaid does provide assistance to eligible individuals, its primary focus is on healthcare coverage rather than offering general monetary benefits.
B. Medicaid is more focused on providing healthcare support rather than offering a minimum level of economic support. Its primary aim is to help cover medical expenses for eligible individuals.
C. Medicaid is designed to help the states defray the expenses for the poor.
Medicaid is a joint federal and state program that assists with medical costs for people with low income, including some low-income adults, children, pregnant women, elderly adults, and people with disabilities.
D. This statement is partially correct but doesn't encompass the full scope of Medicaid. Medicaid provides healthcare coverage for low-income individuals, including the older adult and disabled populations, but it also includes other eligible groups.
Correct Answer is C
Explanation
A. Keeps room temperature at 72°F.
Explanation: Maintaining a room temperature of 72°F is generally considered comfortable and is not likely to contribute to hyperthermia, especially when compared to higher temperatures. However, it's essential to consider individual preferences and comfort levels.
B. Has a history of osteoarthritis.
Explanation: Osteoarthritis itself is not directly associated with an increased risk of hyperthermia. However, limitations in mobility or difficulties with self-care due to osteoarthritis might indirectly impact the ability to stay cool and hydrated, so comprehensive care should consider the overall health status of the individual.
C. Takes furosemide 40 mg daily.
Explanation: Furosemide is a diuretic that increases urine production, leading to fluid loss. Dehydration or electrolyte imbalances resulting from diuretic use can contribute to an increased risk of hyperthermia, especially in hot weather. It's important for healthcare providers to monitor and manage medications, considering their potential effects on fluid balance and thermoregulation.
D. Bathes daily with a hot shower.
Explanation: While taking hot showers may contribute to temporary elevation of body temperature, bathing alone may not be a significant contributor to hyperthermia. However, if an older adult has difficulty tolerating heat or maintaining hydration, it's essential to consider the cumulative impact of various factors.
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