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","B","C","D"]

Explanation

Rationale for Correct Options:

Urge to defecate occurs as the fetal head descends further into the birth canal, putting pressure on the rectum and perineum. This is a common sign of the second stage of labor, indicating that the client is nearing delivery.
Increased bloody show results from cervical dilation and effacement as the capillaries in the cervix rupture. A greater amount of blood-tinged mucus is expected as labor progresses, particularly in the transition phase and early second stage.
Cervix 10 cm dilated confirms that the client has reached full cervical dilation, which is required for the second stage of labor to begin. Complete dilation allows for the passage of the fetus through the birth canal.
Contractions strong on palpation indicate effective uterine activity, which is necessary for fetal descent and expulsion. Strong contractions help in moving the baby downward and increasing pressure on the cervix.

Rationale for Incorrect Options:

A heart rate of 110/min is elevated compared to the client’s earlier readings (90/min at 0830, 110/min at 0845) and may indicate maternal stress or exertion from labor pain. While mild increases in maternal heart rate are expected during labor, tachycardia above 110/min warrants further evaluation, particularly in the presence of fever.
Temperature of 39.1°C (102.4°F). This temperature is abnormally high and suggests infection, such as chorioamnionitis, especially considering the prolonged rupture of membranes since 1900 the previous night. Normal maternal temperature may rise slightly during labor due to exertion, but fever above 38°C (100.4°F) is concerning and requires medical attention.

A. Understands that everyone dies eventually B. Expresses curiosity about the funeral service C. Believes the death is punishment for bad behavior D. Recognizes the parent will never wake up

Correct Answer is C

Explanation

A. "Understands that everyone dies eventually." Preschoolers typically do not have a comprehensive understanding of the concept of death and its universality. Their grasp of death is often more concrete, focusing on the specific situation rather than a general concept.
B. "Expresses curiosity about the funeral service." While some preschoolers may show curiosity about the funeral service, many might find the concept of a funeral confusing. Their understanding of death is often limited, and they may not ask questions about such abstract concepts.
C. "Believes the death is punishment for bad behavior." Preschoolers often have egocentric thinking and may associate events with their own actions, leading them to believe that a parent's death is a form of punishment for their behavior. This is a common response in this age group as they struggle to comprehend death and its causes.
D. "Recognizes the parent will never wake up." Preschoolers typically do not fully grasp the permanence of death. They may believe that the deceased parent will wake up or return, reflecting their limited understanding of the finality of death.

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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.

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","D"]

Explanation

A nurse is caring for a preschooler who recently experienced the death of a parent. Which of the following findings should the nurse identify as consistent with this age group?

Correct Answer is 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.