A nurse is assisting with the care of a client.

Exhibits

Select the 4 responsibilities the nurse has in relation to the client's advance directives.

Communicate advance directives status via the medical record and shift report.

Provide the client with written information about advance directives.

Inform the client that an advance directive discontinues further care.

Instruct the client that an advance directive is a legal document and must be honored by care providers.

Document that the provider discussed do-not-resuscitate status with the client.

Initiate a power of attorney for health care document.

Answer and Explanation

Correct Answer : A,B,D,E

A. Communicate advance directives status via the medical record and shift report. The nurse is responsible for ensuring that all members of the healthcare team are aware of the client’s advance directives. Documenting this information in the medical record and shift report helps guide care in accordance with the client’s wishes.
B. Provide the client with written information about advance directives. Clients have the right to receive information about advance directives, including living wills and do-not-resuscitate (DNR) orders. The nurse should provide educational materials to help the client make informed decisions.
C. Inform the client that an advance directive discontinues further care. An advance directive does not automatically discontinue all medical care. It provides instructions regarding specific interventions the client wishes to accept or decline, such as resuscitation, mechanical ventilation, or artificial nutrition. The nurse should clarify this to avoid misconceptions.
D. Instruct the client that an advance directive is a legal document and must be honored by care providers. Advance directives are legally binding documents that must be followed by healthcare providers. The nurse should reinforce that the client’s wishes, as stated in the directive, will be respected.
E. Document that the provider discussed do-not-resuscitate status with the client. Proper documentation is essential to ensure the client's preferences regarding resuscitation and end-of-life care are acknowledged and followed. The nurse should record discussions regarding advance directives in the medical record.
F. Initiate a power of attorney for health care document. The nurse does not have the authority to initiate a power of attorney for health care. The client must complete this legal document independently or with legal assistance, and it typically requires notarization or witness signatures. The nurse can provide information about it but cannot create or execute it on the client’s behalf.

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Correct Answer is A

Explanation

A. The client reports pain is reduced when he is positioned on his side. This information is relevant to the client's current condition and care plan. Pain management is a critical aspect of nursing care, and informing the oncoming nurse about the client’s preferred position for pain relief ensures continuity of care and appropriate interventions.
B. The client's partner visited earlier today for 2 hours. While social interactions are important for the client’s well-being, this information is not essential for a shift report unless it directly affects the client's condition or care needs.
C. The client's mother died 4 years ago from breast cancer. While family history can be relevant for long-term medical planning, it is not pertinent to the immediate shift report, which should focus on the client's current status and care needs.
D. The client received the prescribed antibiotic every 8 hours. While medication administration is important, the oncoming nurse can verify this information in the medication administration record (MAR). Shift reports typically focus on changes in condition, ongoing concerns, and necessary interventions rather than routine medication schedules.

A. Abdominal cramping B. Diarrhea C. Weight loss D. Anemia

Correct Answer is {"A":{"answers":"A,B,C"},"B":{"answers":"A,C"},"C":{"answers":"A,C"},"D":{"answers":"A,C"}}

Explanation

Abdominal cramping: Present in ulcerative colitis, diverticulitis, and Crohn's disease due to inflammation of the bowel. Ulcerative colitis affects the colon, diverticulitis involves inflamed diverticula, and Crohn’s disease can cause transmural inflammation anywhere in the GI tract.
Diarrhea: A hallmark of ulcerative colitis and Crohn’s disease, resulting from mucosal damage and inflammation. Diverticulitis more commonly presents with constipation or alternating bowel habits rather than persistent diarrhea.
Weight loss: Common in Crohn’s disease due to malabsorption caused by widespread GI involvement. Less likely in ulcerative colitis or diverticulitis unless there is prolonged disease progression or severe complications.
Anemia: Present in both ulcerative colitis and Crohn’s disease due to chronic inflammation and potential GI blood loss. Less common in diverticulitis unless there is active bleeding from perforation or fistula formation.

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A nurse is assisting with the care of a client. Exhibits Select the 4 responsibilities the nurse has in relation to the client's advance directives.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing change-of-shift report for a client. Which of the following information should the nurse include in the report?

Correct Answer is A

Explanation

A nurse is assisting with the care of a client. Exhibits For each data collection finding, dick to specify if the finding is consistent with ulcerative colitis, diverticulitis, or Crohn's disease. Each finding may support more than 1 disease process.

Correct Answer is {"A":{"answers":"A,B,C"},"B":{"answers":"A,C"},"C":{"answers":"A,C"},"D":{"answers":"A,C"}}

Explanation

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A nurse is assisting with the care of a client.

Exhibits

Select the 4 responsibilities the nurse has in relation to the client's advance directives.