A nurse is admitting a client to the medical-surgical unit. The Patient Self-Determination Act requires the nurse to perform which of the following actions during the admission process?

Document in the client's medical record if the client has advance directives.

Ensure the client has an attorney to contact for assistance with end-of-life documents.

Provide end-of-life education if the client has a terminal illness.

Provide the client with a list of eligible individuals who can serve as a health care proxy.

Answer and Explanation

The Correct Answer is A

A. The Patient Self-Determination Act (PSDA) requires health care facilities to ask clients about advance directives upon admission and document their status in the medical record. This ensures that the client’s treatment preferences are known and respected.
B. Ensuring the client has an attorney is not a requirement of the PSDA. Clients may choose legal assistance, but it is not mandated by the act.
C. Providing end-of-life education is beneficial but not specifically required by the PSDA. The act focuses on informing clients of their rights regarding advance directives.
D. The PSDA does not require facilities to provide a list of eligible health care proxies. Instead, it ensures clients are informed of their right to appoint one.

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Correct Answer is C

Explanation

A. Bradycardia is not expected with dehydration. Instead, tachycardia occurs as a compensatory response to low blood volume.
B. Edema is not a symptom of dehydration. Instead, dehydration leads to decreased tissue perfusion and dry mucous membranes.
C. Hypotension occurs due to decreased blood volume from fluid loss, leading to low blood pressure and potential dizziness or weakness.
D. Crackles are not expected in dehydration. Instead, lung sounds are typically clear unless another condition is present.

Correct Answer is []

Explanation

Potential Condition: Opioid intoxication

Actions to Take:

Obtain a prescription for naloxone
Prepare to initiate mechanical ventilation

Parameters to Monitor:

Pupillary reaction,
Respiratory rate

Rationale:

Potential Condition: The client presents with shallow breathing, slurred speech, confusion, pupillary constriction, and bradycardia, which are classic signs of opioid intoxication. The history of back pain also suggests possible opioid use.
Actions to Take:
- Naloxone is an opioid antagonist that can rapidly reverse respiratory depression caused by opioid overdose.
- Mechanical ventilation may be necessary if respiratory depression is severe and does not improve with naloxone administration.
Parameters to Monitor:
- Pupillary reaction is important because opioids cause pupillary constriction (miosis). Improvement in pupillary size and reaction indicates the opioid effects are wearing off.
- Respiratory rate should be closely monitored since opioid overdose primarily affects respiratory drive, leading to hypoxia and potential respiratory failure.

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A nurse is admitting a client to the medical-surgical unit. The Patient Self-Determination Act requires the nurse to perform which of the following actions during the admission process?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has dehydration due to prolonged diarrhea. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

Correct Answer is []

Explanation

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