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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Weight loss is a potential side effect of methylphenidate, but it is not a direct indicator of medication effectiveness.
B. Correct. Improved ability to complete tasks like homework can be a positive indication of the medication's effectiveness in managing ADHD symptoms.
C. Increased caloric intake might not be directly related to the medication's effectiveness.
D. "A better grasp of reality" is a vague statement and not a specific indicator of ADHD medication effectiveness.

A. Countertransference B. Boundary crossing C. Promoting trust D. Veracity

Correct Answer is C

Explanation

A. Incorrect. Countertransference refers to the nurse's emotional reaction to the client based on the nurse's personal feelings or past experiences.
B. Incorrect. Boundary crossing refers to the nurse's actions that blur the professional boundaries of the nurse-client relationship, and this action does not necessarily represent boundary-crossing.
C. Correct. The nurse's action of interrupting the bath to obtain a healthy meal for the client demonstrates an immediate response to the client's need and promotes trust and rapport between the nurse and the client.
D. Incorrect. Veracity refers to truthfulness and honesty, but it does not directly apply to the nurse obtaining a meal for the client who is hungry.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with the parents of a child who has ADHD and is taking methylphenidate. Which of the following statements by the parents indicates that the medication is effective?

Correct Answer is B

Explanation

A nurse begins to bathe a newly admitted client who reports that they have not had anything to eat that day. The nurse interrupts the bath and obtains a healthy meal for the client. This action by the nurse is an example of which of the following?

Correct Answer is C

Explanation

A nurse is caring for a client who is to begin chemotherapy. The client asks the nurse about managing hair loss. Which of the following responses should the nurse make?

A nurse is caring for a client who has a new diagnosis of diabetes mellitus and is refusing to learn how to self-administer Insulin. Which of the following responses should the nurse make?

A nurse is collecting data from a client who has thrombocytopenia. The nurse should identify which of the following findings increases the client's risk for injury.

A nurse is assisting with the care of a client who is receiving a spinal epidural to treat a herniated disc. Which of the following findings should the nurse identify as an indicator of unrelieved pain?

A nurse is collecting data from a client who is expressing suicidal ideations. Which of the following s is the nurse's priority?

A nurse is caring for a client who has HIV and is neutropenic. Which of the following findings should the nurse identify as increasing the risk for the client to develop an infection?

A nurse is assisting with postmortem care for a client who was a devout follower of Islam. Which of the following actions should the nurse take?

A home health nurse is conducting a home inspection for a client who is at risk for falls. Which of the following instructions should the nurse provide for the client?