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 B
Explanation
A. He is able to name objects with which he comes in contact correctly.
Explanation: Being able to name objects correctly indicates intact language and object recognition skills, which are positive aspects of cognitive function.
B. He is constantly checking to see whether what he did is correct.
Explanation: Constantly checking to see whether what he did is correct may be an indicator of anxiety or uncertainty about cognitive performance. While this behavior alone does not confirm cognitive impairment, it raises a question about the individual's confidence or potential challenges in decision-making.
C. He is able to hold a conversation with you.
Explanation: Holding a conversation demonstrates language and communication abilities, suggesting intact cognitive skills for social interaction.
D. His attention span will last as long as the project he is working on.
Explanation: Having an attention span that matches the duration of a project suggests a focused and goal-oriented approach, which can be a positive aspect of cognitive function.
Correct Answer is B
Explanation
A. Tell her to use an assistive device until her balance improves.
Explanation: While using an assistive device may provide support, it is not a comprehensive solution for improving balance. Addressing balance issues usually involves a combination of exercises and interventions tailored to the individual's needs.
B. Provide information on group exercises for balance training.
Explanation: Group exercises specifically designed for balance training can be beneficial for an older adult who is recovering from balance issues and falls. These programs often include exercises targeting stability, coordination, and strength, and they are led by professionals who can provide guidance and supervision. Group exercises also offer a social component, promoting motivation and adherence to the program.
C. Instruct her to enroll in a general exercise program for 8 weeks.
Explanation: A general exercise program may not specifically focus on balance training. Tailoring the program to address balance issues is more appropriate for the client's needs.
D. Help her to learn how to exercise the core group of muscles.
Explanation: While exercising the core muscles can contribute to overall stability, a broader approach that includes balance-specific exercises is preferable for someone recovering from balance issues and falls. Balance training often involves exercises that target various muscle groups involved in maintaining stability.
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