A hospice nurse is planning care for a client who does not have advance directives. Which of the following interventions should the nurse include in the plan of care?
Provide the client with information about advance directives.
Encourage the client to contact an attorney to create advance directives.
Inform the client that they will need a relative to witness their advance directives.
Tell the client that The Joint Commission requires clients to have advance directives.
The Correct Answer is A
Choice A rationale:
Providing the client with information about advance directives is an appropriate intervention. Advance directives are legal documents that allow individuals to communicate their preferences for medical treatment in the event they become unable to make decisions for themselves. Educating the client about the importance and benefits of advance directives empowers them to make informed decisions about their care.
Choice B rationale:
Encouraging the client to contact an attorney to create advance directives is not the primary responsibility of the hospice nurse. While legal assistance might be helpful, the nurse should first ensure that the client understands the concept of advance directives and their significance before suggesting legal involvement.
Choice C rationale:
Informing the client that they will need a relative to witness their advance directives is not accurate. While witnesses are often required when signing legal documents, the specific requirements for advance directives can vary by jurisdiction. It's important for the nurse to provide accurate information and not make assumptions about legal processes.
Choice D rationale:
Telling the client that The Joint Commission requires clients to have advance directives is not accurate. While The Joint Commission emphasizes the importance of patient rights and informed decision-making, it does not mandate that all clients must have advance directives. The decision to create advance directives is a personal choice and should be based on the individual's values and preferences.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
A podiatrist specializes in foot-related issues. Osteoarthritis primarily affects joints, so referring the client to a podiatrist would not directly address their difficulty in buttoning clothes.
Choice B rationale:
A social worker typically addresses psychosocial needs, including emotional and financial concerns. While important, this role wouldn't directly address the client's physical difficulty with buttoning clothes due to osteoarthritis.
Choice C rationale:
Paramedical technologists are skilled in various diagnostic tests and procedures. However, they are not directly involved in assisting clients with activities of daily living or improving physical function.
Choice D rationale:
An occupational therapist (OT) specializes in helping clients regain and enhance their ability to perform daily activities, such as dressing, grooming, and self-care. For the client with osteoarthritis struggling to button clothes, an OT would assess their physical limitations and provide strategies or adaptive tools to improve independence in these activities.
Correct Answer is D
Explanation
Choice A rationale:
A client who has a penetrating head injury and a respiratory rate of 4/min requires immediate attention due to the critical nature of the head injury and the dangerously low respiratory rate. However, in an emergency situation like this, the priority would be a condition that could be rapidly fatal if not addressed promptly.
Choice B rationale:
A client with a comminuted fracture of the femur has a serious injury that requires assessment and treatment, but it is not an immediately life-threatening condition. It falls lower in the priority compared to conditions that directly impact respiratory and cardiovascular function.
Choice C rationale:
A client with a 15.2-cm laceration to the scalp with clotted blood visible also requires attention, but it is not as time-sensitive as a life-threatening condition. Controlling bleeding and cleaning the wound can be addressed after addressing more critical cases.
Choice D rationale:
Correct. A client with a sucking chest wound has a high risk of tension pneumothorax, a condition where air accumulates in the pleural space, leading to lung collapse and compromised circulation. This condition can be rapidly fatal. Immediate intervention is required to seal the wound and prevent further air from entering the pleural space.
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