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?

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

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

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

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

Answer and Explanation

The Correct Answer is B

Choice A rationale:

While providing end-of-life education is important, it is not a specific requirement under the Patient Self-Determination Act. The act primarily focuses on ensuring that patients' wishes regarding medical treatment and interventions are respected through advance directives.

Choice B rationale:

Documenting in the client's medical record if the client has advance directives is a requirement under the Patient Self-Determination Act. This documentation ensures that healthcare providers are aware of the patient's preferences regarding medical treatment, especially in end-of-life situations. Advance directives may include living wills or durable power of attorney for healthcare, allowing patients to express their choices regarding medical interventions and appointing someone to make decisions on their behalf if they are unable to do so.

Choice C rationale:

Providing the client with a list of eligible individuals who can serve as a health care proxy is not a requirement under the Patient Self-Determination Act. While it can be helpful, the act primarily emphasizes documenting and respecting the patient's existing advance directives.

Choice D rationale:

Ensuring the client has an attorney for assistance with end-of-life documents is not a requirement under the Patient Self-Determination Act. While legal advice can be beneficial, the act primarily focuses on healthcare providers' responsibilities in documenting and respecting patients' advance directives.

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Correct Answer is C

Explanation

- A. Hypotension is not an adverse effect of epinephrine, but rather a sign of anaphylaxis that epinephrine can help to reverse by causing vasoconstriction and increasing blood pressure.

- B. Report of tinnitus is not an adverse effect of epinephrine, but rather a symptom of aspirin toxicity, which can occur in some clients who take aspirin for allergic reactions.

- C. Report of chest pain is an adverse effect of epinephrine, as it can cause cardiac dysrhythmias, angina, and myocardial ischemia by increasing the heart rate and oxygen demand of the myocardium.

-D. Ecchymosis is not an adverse effect of epinephrine, but rather a sign of bleeding disorders or trauma that can cause bruising under the skin.

A. "I should store my personal items all together on the shelf in my bathroom.” B. "I will wear a yellow wristband so everyone knows I am at risk of falling.” C. "I should keep the overhead lights on at all times while I am here.” D. "I will have to wear a restraint around my waist when I am sitting up in a chair.”

Correct Answer is A

Explanation

Choice A rationale:

Storing personal items together on a shelf in the bathroom promotes organization and reduces the risk of tripping or falling over scattered items. Keeping the environment tidy and free of clutter is an essential fall prevention strategy, especially in areas where the client moves frequently.

Choice Brationale:

Wearing a yellow wristband to indicate a fall risk is a common practice in healthcare facilities. However, merely wearing the wristband does not demonstrate a comprehensive understanding of fall prevention strategies. While it is essential for healthcare providers to identify patients at risk of falling, educating the patient about specific strategies to prevent falls is equally important.

Choice C rationale:

Keeping the overhead lights on at all times does not necessarily indicate an understanding of fall prevention strategies. While adequate lighting is important to prevent falls, leaving lights on continuously may not be necessary during daylight hours. It is more effective to ensure there is adequate lighting in commonly used areas and during nighttime hours.

Choice Drationale:

Wearing a restraint around the waist is not a recommended fall prevention strategy. Physical restraints are generally discouraged in healthcare settings due to ethical concerns and the potential to cause harm to the patient. Restraints can lead to complications such as pressure ulcers, loss of muscle strength, and decreased mobility.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client after administering epinephrine for an anaphylactic reaction. Which of the following findings should the nurse identify as an adverse effect of this medication?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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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?