A nurse is assisting with the care of a client.
Π
Nurses' Notes 1000:
The client states, "I am tired of undergoing treatment because it doesn't seem to be working." The client states, "I hope I am just constipated." Appendectomy scar on the right lower quadrant. The abdomen is soft, and tender in the right lower quadrant, bowel sounds present in all four quadrants.
1200:
The surgeon has notified the client that surgical removal of the mass is advisable due to the client's history of metastasis and ongoing treatment failure. The client and their partner want to discuss end-of-life care. The client states, "I am unsure what it means to have a living will or a do not resuscitate order." The client's partner states, "I don't understand what power of attorney means." Both client and partner indicate that they might wish to decline further treatment as well as further lifesaving measures should they become necessary. The partner states, "How can we be sure that our decision about care will be honored?"
Select the responsibilities the nurse has in relation to the client's advance directives.
Provide the client with written information about advance directives.
Document that the provider discussed do not resuscitate status with the client. Inform the client that an advance directive discontinues further care.
Communicate advance directives status via the medical record and shift report. Instruct the client that an advance directive is a legal document and must be honored by care providers.
Initiate a power of attorney for health care documents.
Correct Answer : A,C,D
A. The nurse should provide the client with written information about advance directives to ensure that the client fully understands their options and can make informed decisions about their healthcare wishes.
B. Not a correct option because it inaccurately states that an advance directive discontinues further care. An advance directive guides the type of care a patient wants or does not want, but it does not automatically discontinue all care.
C. The nurse should communicate the client's advance directives status to other members of the healthcare team through documentation and shift reports. The nurse should also educate the client that an advance directive is a legal document that guides healthcare decisions and must be respected by care providers.
D. The nurse can assist the client in initiating a power of attorney for health care document, which designates a trusted person to make healthcare decisions on behalf of the client if they become unable to make decisions for themselves.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. Gathering information about the child's dietary history is the first step to understanding the potential underlying causes of poor intake.
B. Incorrect. Offering nutritious snacks is important, but understanding the child's history is a higher priority.
C. Incorrect. While family presence during mealtimes is important, addressing the child's dietary intake takes precedence.
D. Incorrect. Praise is important but doesn't address the underlying issue of poor dietary intake.
Correct Answer is C
Explanation
Restlessness can be a common manifestation of pain. When a client is experiencing unrelieved pain, they may exhibit restlessness, which can include fidgeting, pacing, or frequent position changes in an attempt to find relief. Restlessness may also be accompanied by increased heart rate, elevated blood pressure, and changes in respiratory rate.
Difficulty swallowing (dysphagia) is not a specific indicator of unrelieved pain in a client with a spinal epidural for a herniated disc. Difficulty swallowing can be caused by various factors, including anatomical abnormalities, neurological conditions, or muscle dysfunction.
Constipation is not a specific indicator of unrelieved pain in this scenario. Constipation can be a side effect of certain medications, including opioids that are commonly used to manage pain.
However, it is not an exclusive indicator of unrelieved pain and can be managed through interventions such as adequate hydration, fiber intake, and appropriate bowel regimen.
Urinary retention is not a specific indicator of unrelieved pain in this context. It can be associated with several factors, including the use of certain medications, urinary tract infections, or neurological conditions. Urinary retention may require assessment and management but does not necessarily indicate unrelieved pain.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today