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.

Answer and Explanation

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Four-length rails.

Explanation: Four-length rails fully enclose the bed and can be considered a more restrictive measure. They may be used when a restraint order is in place, but for an alert patient without such an order, less restrictive alternatives are preferred.

B. One-length rail.

Explanation: Using one-length rails can be a less restrictive alternative when a patient is at high risk for falling. The use of one side rail allows for some protection against falls without fully restraining the patient. This approach helps maintain the patient's mobility and autonomy while still providing a safety measure.

C. Two full-length rails.

Explanation: While using two full-length rails is less restrictive than four-length rails, it is still more restrictive than using only one side rail. The goal is to balance fall prevention with the patient's autonomy.

D. No side rails.

Explanation: Using no side rails may not provide adequate protection for an alert patient at high risk for falling. While avoiding restraints is essential, implementing at least one side rail is a reasonable compromise to enhance safety without fully restricting the patient's movement.

A. "Use of drugs results in minimal improvement in appetite and weight gain and can have some serious side effects." B. There are no drugs that impact appetite or weight gain." C. These drugs are not permitted to be used in a long term care facility" D. Yes, there are some very effective drugs out there. Your mother should be on one of them

Correct Answer is A

Explanation

A. "Use of drugs results in minimal improvement in appetite and weight gain and can have some serious side effects."

Explanation: It is important for the nurse to provide accurate and balanced information about the use of drugs to stimulate appetite. While there are medications available that may be prescribed to improve appetite in certain situations, it is crucial to convey that the effectiveness of such drugs is limited, and they can also have potential serious side effects. Additionally, the decision to use appetite-stimulating drugs should be carefully considered, taking into account the individual's overall health, medical conditions, and potential risks associated with the medications.

B. "There are no drugs that impact appetite or weight gain."

Explanation: This statement is not accurate, as there are medications that may impact appetite and weight gain. However, the effectiveness and appropriateness of such medications should be assessed on a case-by-case basis.

C. "These drugs are not permitted to be used in a long term care facility."

Explanation: This statement is not accurate. The use of appetite-stimulating drugs may be permitted in long-term care facilities, but their use is typically based on individual assessment and consideration of potential risks and benefits.

D. "Yes, there are some very effective drugs out there. Your mother should be on one of them."

Explanation: This statement oversimplifies the decision-making process and may not provide adequate information about the potential risks and benefits of appetite-stimulating drugs. The decision to use such drugs should be made in consultation with the healthcare team, considering the individual's specific circumstances.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The health care provider has not ordered the use of a restraint for an alert patient at high risk for falling. The nurse should implement which side rail use?

Correct Answer is B

Explanation

A resident's family member is concerned that the resident is not eating adequately and is at risk for malnutrition. The family member says to a nurse, "I heard that there are drugs that can make my mother eat better. Do you think she should be on one?" What is the best response by the nurse?

Correct Answer is A

Explanation

In reviewing an older adult's insurance history, you find that he is on Medicaid. What do you know that Medicaid is used for?

In reviewing an older adult's insurance history, you find that he is on Medicaid. What do you know that Medicaid is used for?

An older client is being discharged from the hospital to a sub-acute unit. The client says to a nurse, "I am not sure I understand the difference between a sub-acute unit and a nursing home. Can you help me understand?" The nurse considers which of the following in formulating a response:

Which patient assessment data does the nurse recognize could contribute to an older adult's risk of hyperthermia?

As a nurse caring for a cognitively impaired older adult client, you need to observe for which of the following? (Select all that apply.)

To prevent malnutrition in older clients with dementia, which of the following would benefit your client? (Select all that apply.)

Which recommendations for daily food intake is correct for older adults according to the MyPlate for Older Adults? (Select all that apply.)

When assessing your client who has a history of falls, you should pay particular attention to which of the following? (Select all that apply.)