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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While using an assistive device can be helpful, it's more of a compensatory measure and does not directly address the improvement of balance. It's important to focus on interventions that enhance balance rather than relying solely on external devices.
B. Providing information on group exercises for balance training is a suitable intervention.
Group exercises specifically targeting balance can offer a supportive and structured environment for the older adult.
Balance training in a group setting can provide social interaction, motivation, and a sense of community, which can contribute to adherence and engagement in the program.
C. Enrolling in a general exercise program for 8 weeks may not be as targeted or tailored to the specific needs of someone recovering from balance issues. Specific balance training exercises would likely be more beneficial.
D. Learning how to exercise the core group of muscles is important for overall strength and stability, but it may not be sufficient in addressing balance issues comprehensively. Balance-specific exercises should also be included.
Correct Answer is D
Explanation
A. HIPAA (Health Insurance Portability and Accountability Act)
Explanation: HIPAA, enacted in 1996, focuses on protecting the privacy and security of individuals' health information. While it is essential in healthcare, it is not directly connected to the nursing home reform mandated by the 1987 law.
B. OASIS (Outcome and Assessment Information Set)
Explanation: OASIS is a set of standardized assessments used in home health care, primarily for Medicare-certified home health agencies. It is not directly connected to the nursing home reform mandated by the 1987 law.
C. Fulmer SPICES
Explanation: Fulmer SPICES is a tool used for assessing common geriatric syndromes, but it is not specifically associated with the nursing home reform mandated by the 1987 law.
D. Resident Assessment Instrument (RAI).
Explanation: The Resident Assessment Instrument (RAI) is associated with nursing home reform mandated by the Omnibus Budget Reconciliation Act (OBRA) of 1987. OBRA '87 established regulations and standards for nursing homes, including requirements for comprehensive assessments, care planning, and quality of care. The RAI, specifically the Minimum Data Set (MDS), is a standardized assessment tool used to evaluate the health status and needs of nursing home residents, ensuring a consistent and comprehensive approach to resident assessment and care planning.
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