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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
A. Women have significantly higher mortality rates from hip fractures than do men.
Explanation: This statement is generally true. Women, particularly older women, tend to have higher mortality rates associated with hip fractures compared to men. This is partly because women are more prone to osteoporosis, a condition that increases the risk of fractures.
B. Hip fractures are associated with very high morbidity and mortality.
Explanation: This statement is generally true. Hip fractures can have significant consequences, including increased morbidity and mortality. Complications, such as infections, immobility-related issues, and other medical conditions, can contribute to the overall impact on health.
C. Hip fractures are a leading cause of hospitalization for older people.
Explanation: This statement is generally true. Hip fractures are a common reason for hospitalization among older adults. The severity of the injury often requires medical intervention, surgery, and rehabilitation.
D. Nearly all older patients who sustain a hip fracture will regain prefracture mobility status within 1 year.
Explanation: This statement is not accurate. While many older patients can regain some mobility with appropriate rehabilitation, not all will regain their prefracture mobility status. The extent of recovery varies among individuals and depends on factors such as overall health, comorbidities, and the severity of the fracture.
E. The major cause of hip fractures is falls.
Explanation: This statement is accurate. Falls are a major cause of hip fractures in older adults. Understanding and addressing factors contributing to falls are essential in preventing hip fractures.
Correct Answer is ["B","C","D"]
Explanation
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.
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