A nurse is assisting with the care of a client. Select

A nurse is assisting with the care of a client.

Select the 4 responsibilities the nurse has in relation to the client's advance directives.

Initiate a power of attorney for health care document.

Provide the client with written information about advance directives.

Document that the provider discussed do-not-resuscitate status with the client.

Instruct the client that an advance directive is a legal document and must be honored by care providers.

Communicate advance directives status via the medical record and shift report.

Inform the client that an advance directive discontinues further care.

Answer and Explanation

Correct Answer : B,C,D,E

Initiate a power of attorney for health care document: Nurses do not initiate or create legal documents like a power of attorney. The client must initiate this, often with legal assistance if needed.
Provide the client with written information about advance directives: It is the nurse’s responsibility to ensure the client receives clear, written information about advance directives, including explanations of living wills, DNR orders, and medical power of attorney documents.
Instruct the client that an advance directive is a legal document and must be honored by care providers: Nurses reinforce that advance directives are legally binding documents. They ensure the client's wishes are respected by the healthcare team throughout their care.
Communicate advance directives status via the medical record and shift report: Once a client’s advance directive status is known, it must be accurately documented and communicated to all healthcare providers to ensure continuity and adherence to the client’s wishes.
Document that the provider discussed do-not-resuscitate status with the client: Nurses are responsible for documenting that the conversation regarding DNR status occurred, including who had the conversation and the client's stated wishes, even though the actual discussion is led by the provider.
Inform the client that an advance directive discontinues further care: Advance directives do not mean that all care is discontinued. Clients can still receive comfort, palliative, or supportive treatments based on their wishes outlined in the directive.

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Correct Answer is B

Explanation

A. Request the family members leave the client's room: Family members may choose to stay if they wish, and they should be allowed to participate or be present during postmortem care if it aligns with their emotional needs or cultural practices. Forcing them to leave is not appropriate unless required for specific procedures.

B. Place dentures in the client's mouth: Placing dentures helps maintain the natural shape and appearance of the face, offering a more familiar and comforting appearance for the family during viewing. This is an important step in preparing the body respectfully.

C. Remove the client's personal hair pieces: Hairpieces should be left in place unless the family or facility policy requests otherwise. Removing them without need can alter the client’s appearance and potentially distress the family.

D. Lower the head of the client's bed: The head of the bed should be elevated slightly, not lowered, to prevent blood from pooling in the head and face, which could cause discoloration and swelling before the family views the body.

A. Reviewing client education B. identifying problem-solving skills C. Summarizing the goals and objectives achieved D. Specifying a contract

Correct Answer is B

Explanation

A. Reviewing client education: Reviewing education is often part of the termination phase, where teaching is reinforced and the nurse ensures the client understands care plans after the therapeutic relationship ends. It is not a primary focus during the working phase.

B. Identifying problem-solving skills: The working phase focuses on active problem-solving, setting goals, and implementing strategies to address the client's issues. This is when trust is established further, and the nurse and client collaborate on interventions and coping techniques to promote positive outcomes.

C. Summarizing the goals and objectives achieved: Summarizing achievements is part of the termination phase, when the nurse and client reflect on progress made. It helps bring closure to the relationship but does not belong to the working phase where the focus is still on active progress.

D. Specifying a contract: Specifying a contract is a task of the orientation phase, where the structure of the nurse-client relationship, roles, and expectations are defined. This lays the foundation before entering into the problem-solving focus of the working phase.

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Area assessed	Findings
Neurological	Drowsy but easy to arouse
Vital Signs	Temperature 35.3°C (95.5° F) Heart rate 60/min Respiratory rate 16/min Blood pressure 90/60 mm Hg Oxygen saturation 94% (oxygen at 2 L/min via nasal cannula) Rates pain as 1 on 0/10 pain scale.
Integumentary	Skin cool and moist to touch.
Cardiopulmonary	Heart rate regular. Pedal pulse +1 bilateral. Lungs clear bilateral. Respirations even, nonlabored.
Abdomen	Abdomen soft, nondistended. Bowel sounds hypoactive in all four quadrants. 2x2 gauze with a clear transparent dressing intact to right lower and upper abdominal quadrant. Moderate amount of sanguineous drainage noted on the lower dressing

A nurse is assisting with the care of a client.

Select the 4 responsibilities the nurse has in relation to the client's advance directives.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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A nurse is assisting with the care of a client. Select the 4 responsibilities the nurse has in relation to the client's advance directives.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing the body of a client who is deceased to be viewed by the family. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is discussing the components of the working phase of the nurse-client relationship with a client. Which of the following tasks are specific for this stage to create a therapeutic environment?

Correct Answer is B

Explanation

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A nurse is assisting with the care of a client.

Select the 4 responsibilities the nurse has in relation to the client's advance directives.