A nurse is assisting with the care of a client.
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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. This response acknowledges the client's feelings and demonstrates empathy. It opens the door for further discussion and exploration of the client's beliefs without immediately challenging them.
B. Incorrect. Directly contradicting the client's beliefs may cause resistance and increase their distress. It's important to approach the situation with sensitivity and understanding.
C. Incorrect. While asking for clarification is a valid approach, it may not be the most appropriate initial response. It's important to establish trust and rapport with the client before delving into their delusional beliefs.
D. Incorrect. Asking "why" s may put the client on the defensive and may not lead to a productive conversation about their beliefs. It's better to approach the situation with empathy and openness before exploring the client's perspective.
Correct Answer is D
Explanation
Stevens-Johnson syndrome (SJS) is a severe and potentially life-threatening skin reaction that can occur as a rare but serious side effect of allopurinol. The initial symptom often presents as a skin rash, which can progress rapidly and involve other mucous membranes such as the mouth and eyes. Fever is commonly associated with SJS.
Diplopia (double vision) is not a typical symptom of SJS. It refers to seeing two images instead of one and can be caused by various factors unrelated to allopurinol or SJS.
Tinnitus with ear pain is not a characteristic symptom of SJS. It usually relates to issues with the auditory system, such as damage to the inner ear or other underlying conditions.
Hyperreflexia (exaggerated reflexes) is not directly associated with SJS. It typically refers to an abnormal increase in the body's reflex responses and can be caused by conditions affecting the central nervous system or spinal cord.
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