A nurse is assisting with the admission of a client who is scheduled for surgery. Which of the following actions should the nurse take?

Delay the admission while the client fills out the facility’s advance directives form.

Confirm with the client’s family that the consent form has been signed.

Explain to the client that signing the facility’s consent form means they cannot refuse care.

Determine if the client has prepared their advance directives.

Answer and Explanation

The Correct Answer is D

The nurse should determine if the client has prepared their advance directives, which are legal documents that specify the client’s wishes regarding medical care in case they become incapacitated. Advance directives can include a living will, a durable power of attorney for health care, or a do-not-resuscitate order. The nurse should respect the client’s autonomy and right to self-determination by asking about their advance directives and ensuring that they are documented and followed.

Choice A is wrong because the nurse should not delay the admission while the client fills out the facility’s advance directives form.

The client has the right to refuse or accept any treatment, including filling out an advance directives form.

The nurse should inform the client about the benefits of having advance directives, but should not coerce or pressure them to complete one.

Choice B is wrong because the nurse should not confirm with the client’s family that the consent form has been signed.

The consent form is a legal document that indicates that the client has given informed consent for the surgery, which means that they have received adequate information about the procedure, its risks and benefits, and alternative options.

The consent form should be signed by the client, unless they are a minor, mentally incompetent, or unable to communicate.

The nurse should verify that the consent form has been signed by the client or their legal representative before the surgery.

Choice C is wrong because the nurse should not explain to the client that signing the facility’s consent form means they cannot refuse care.

Signing the consent form does not waive the client’s right to withdraw consent at any time before or during the surgery.

The nurse should inform the client that they can change their mind and refuse care at any point, and that their decision will be respected and honored.

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Correct Answer is D

Explanation

A client who is 1 day postpartum and has not voided in 8 hr. This client is at risk of urinary retention, bladder distension, and infection due to the effects of epidural anesthesia, perineal trauma, and fluid shifts after delivery. The nurse should assess the client’s bladder and catheterize if necessary.

Choice A is wrong because a client who is 2 days postpartum and whose fundus is 2 to 4 cm below the umbilicus is showing a normal finding.

The fundus should descend about 1 to 2 cm per day after delivery and be nonpalpable by day 10.

Choice B is wrong because a client who is 3 days postpartum and has not had a bowel movement since prior to admission is not uncommon.

Constipation is a common problem after delivery due to decreased peristalsis, dehydration, and fear of pain.

The nurse should encourage fluid intake, fiber intake, and early ambulation to promote bowel function.

Choice C is wrong because a client who is 4 days postpartum and has lochia serosa is also showing a normal finding.

Lochia serosa is the pinkish-brown discharge that occurs from day 4 to 10 after delivery.

It consists of old blood, serum, leukocytes, and tissue debris.

A. Anhedonia. B. Distractibility. C. Grandiose thinking. D. Overeating. E. Flight of ideas.

Correct Answer is ["B","C","E"]

Explanation

Correct Answers:Distractibility. Grandiose thinking. Flight of ideas.

These are the common symptoms of mania in bipolar disorder.

Some possible explanations for the other choices are:

Choice A is wrong because anhedonia, which means loss of interest or pleasure in activities, is a symptom of depression, not mania.
Choice D is wrong because overeating is not a specific symptom of mania, although some people with bipolar disorder may have changes in appetite or weight during mood episodes.

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A nurse is assisting with the admission of a client who is scheduled for surgery. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a postpartum unit is caring for a group of clients. Which of the following clients is the nurse’s priority?

Correct Answer is D

Explanation

A nurse is monitoring a client who has bipolar disorder and is exhibiting manifestations of mania. Which of the following findings should the nurse expect? (Select all that apply.).

Correct Answer is ["B","C","E"]

Explanation

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