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.

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 D

Explanation

A. Understands that everyone dies eventually: Preschoolers typically do not have a concrete understanding of the concept of death or the inevitability of death for everyone. Their understanding is usually very limited and concrete, so this would not be consistent with their developmental stage.

B. Recognizes the parent will never wake up: Preschoolers may have difficulty understanding the permanence of death. They might think that the deceased parent will wake up eventually or return, as their grasp on the concept of permanence is not fully developed.

C. Expresses curiosity about the funeral service: While preschoolers may be curious about many things, including new experiences, their understanding of a funeral and its significance may be limited. They might not fully grasp the meaning behind the service but may ask questions out of curiosity.

D. Believes death is punishment for bad behavior: Preschoolers often think in magical or egocentric ways and may believe that death is a punishment for something they or others did wrong. This belief reflects their developmental stage, where they may not understand the abstract concept of death and may interpret it in relation to their own actions or behaviors.

A. Insomnia B. Diarrhea C. Weight loss D. Diaphoresis

Correct Answer is A

Explanation

A. Correct. Insomnia, or difficulty falling asleep or staying asleep, is a common manifestation of nicotine withdrawal.
B. Diarrhea is not a typical manifestation of nicotine withdrawal.
C. Weight gain, not weight loss, is more commonly associated with nicotine withdrawal.
D. Diaphoresis (excessive sweating. can be associated with nicotine withdrawal, but insomnia is a more direct withdrawal symptom.

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Naxlex Comprehensive Predictor Exams

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 D

Explanation

A nurse is reinforcing teaching with a client who is dependent on nicotine and wishes to discontinue smoking. The nurse should inform the client that which of the following is a manifestation of nicotine withdrawal?

Correct Answer is A

Explanation

A home health nurse is caring for a client who has Alzheimer's disease. The client's son is concerned about his mother becoming frustrated. Which of the following interventions should the nurse include?

A nurse is verifying informed consent for a client who is preoperative for a vaginal hysterectomy. Which of the following statements should the nurse identify as an indication that the client has given informed consent?

A nurse is reviewing the plan of care for a group of clients. The nurse should identify that informed consent is required for which of the following procedures?

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 in a long-term care facility is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA. Which of the following actions should the nurse take?

A nurse at a long-term care facility is reviewing the plan of care for a client who has a prescription for mitten restraints. Which of the following tasks should the nurse assign to an assistive personnel?

A nurse is collecting data from a client who is 2 days postpartum. The client tells the nurse she cannot afford to pay for baby formula. The nurse should refer the client to which of the following members of the interprofessional team?

A nurse on a mental health unit is caring for a client who is in restraints. Which of the following actions should the nurse take?