A male client with a chronic medical condition tells the practical nurse (PN) that he wants no heroics to prolong his life if anything should happen to him. Which action should the PN take?
Place a "Do Not Resuscitate" sign outside the client's door and at the bedside.
Reassure the client that life-saving measures will not be taken without consent.
Complete an advance directive form and place it in the medical record.
Notify the client's healthcare provider of the client's wishes as soon as possible.
The Correct Answer is D
A. "Place a 'Do Not Resuscitate' sign outside the client's door and at the bedside."
A DNR order must be written by the healthcare provider and documented in the medical record. A sign alone is not sufficient to ensure the client’s wishes are followed.
B. "Reassure the client that life-saving measures will not be taken without consent."
While reassuring the client is important, the client’s wishes must be documented formally through an advance directive, which is legally binding and ensures that medical staff are aware of and follow the client’s instructions.
C. "Complete an advance directive form and place it in the medical record."
While completing an advance directive is important, the first priority is notifying the healthcare provider so that the client’s wishes can be documented and the proper legal forms can be completed.
D. "Notify the client's healthcare provider of the client's wishes as soon as possible."
The nurse should immediately notify the healthcare provider of the client’s wishes. The healthcare provider can then initiate the appropriate legal documentation, such as a DNR order or an advance directive, ensuring the client’s wishes are respected in the future. This is the first step in ensuring that the client’s preferences are followed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This statement suggests that the client has found sources of emotional support and is relying on them to cope with the challenges posed by his prognosis. Acceptance of a prognosis often involves coming to terms with the reality of the situation and finding ways to manage the emotional and practical aspects of it. By acknowledging the support he has received from his faith and family, the client demonstrates a willingness to lean on these resources for strength and comfort.
The other statements do not necessarily reflect acceptance of the prognosis:
A. "I think I had this disease for a long time, but the doctor did not find it." This statement implies a sense of disbelief or frustration with the delay in diagnosing the disease, rather than acceptance of the prognosis itself.
C. "I understand this is a disease that occurs mostly in older men." While this statement shows some awareness of the disease, it does not necessarily indicate acceptance. It may simply reflect an understanding of the demographics of prostate cancer without addressing the client's personal feelings or coping mechanisms.
D. "I do not have any use for those who say this disease is going to win." This statement may indicate resistance or defiance towards the negative outlook associated with the disease. It suggests a desire to maintain a positive attitude but does not necessarily reflect a full acceptance of the prognosis and its implications.
Correct Answer is C
Explanation
Circumoral cyanosis, which is bluish discoloration around the mouth, can be a sign of inadequate oxygenation. It suggests that there may be an issue with the infant's respiratory or cardiovascular system, potentially indicating respiratory distress or a cardiac problem. Prompt assessment and intervention are necessary to determine the cause of the cyanosis and ensure the infant's well-being.
A. The six-hour-old infant with a large sacral "stork bite" refers to a common birthmark caused by dilated blood vessels. While it may be important to assess the birthmark and document its presence, it is not an urgent concern requiring immediate attention.
B. The two-day-old infant with a negative Ortolani's sign refers to a specific maneuver used to assess for developmental hip dysplasia or dislocation. A negative Ortolani sign indicates that there is no evidence of hip dislocation. While it is important to assess the infant's hips and document the findings, it does not require immediate attention.
D. The one-day-old infant with a positive Babinski's reflex refers to an abnormal response in which the infant's toes fan out and the big toe dorsiflexes when the sole of the foot is stimulated. While a positive Babinski's reflex can be a normal finding in infants under a certain age, it is important to assess the infant's neurological status. However, it does not require immediate attention compared to the infant with circumoral cyanosis, which indicates potential respiratory or cardiovascular distress.
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