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?

A. A standard assessment tool will increase the likelihood of obtaining accurate data.

Explanation: Standardized assessment tools, like the Mini-Cog, are designed to provide consistent and objective measures of specific aspects of a client's health, in this case, mental status. Using such tools helps ensure a standardized and systematic approach to data collection, increasing the reliability and accuracy of the information gathered. This, in turn, contributes to a more comprehensive understanding of the client's health status.

B. A standard assessment tool is required by Medicare and Medicaid.

Explanation: While some standardized assessment tools may be recommended or required by certain healthcare agencies or institutions, there isn't a broad requirement from Medicare and Medicaid for a specific tool. The use of assessment tools may vary based on clinical judgment and institutional policies.

C. A standard assessment tool will increase reimbursement by Medicare and Medicaid.

Explanation: The use of a specific assessment tool is not a direct factor that influences reimbursement by Medicare and Medicaid. Reimbursement is typically based on the overall care provided and documented, rather than the specific assessment tool used.

D. A standard assessment tool will increase the client's confidence in the nurse.

Explanation: While utilizing a standard assessment tool may contribute to the overall professionalism and thoroughness of care, the primary purpose is to obtain accurate and objective data rather than specifically increasing the client's confidence in the nurse. Confidence is often influenced by the nurse's communication, empathy, and overall competence in providing care.

A. Use absorbent incontinent pads.
Explanation: While absorbent incontinent pads are useful for managing incontinence, they do not directly contribute to preventing hypothermia. Maintaining warmth through appropriate clothing and insulation is more relevant to hypothermia prevention.

B. Eat high-protein meals.
Explanation: Consuming high-protein meals is important for maintaining energy and body heat. Protein metabolism produces heat as a byproduct, contributing to overall warmth.

C. Layer clothing and bedclothes.
Explanation: Layering helps trap warmth close to the body, providing insulation. This is an effective strategy to prevent heat loss and maintain body temperature.

D. Use a head covering.
Explanation: A significant amount of heat is lost through the head. Wearing a head covering, such as a hat or a cap, helps to minimize heat loss and maintain body temperature.

E. Use your comfort level to set the thermostat.
Explanation: Relying solely on personal comfort to set the thermostat may not provide adequate protection against hypothermia. It is important to keep indoor temperatures at a level that ensures warmth and minimizes the risk of cold exposure, especially for elderly individuals who may be more susceptible to temperature extremes.