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 A

Explanation

A. Frequent swallowing: Frequent swallowing after a tonsillectomy can be a sign of active bleeding from the surgical site. Even if bleeding is not visible, the child may be swallowing blood, which can lead to significant hemorrhage. This is the priority finding that requires immediate intervention.

B. Report of sore throat: A sore throat is an expected and normal finding after a tonsillectomy due to surgical trauma and healing. It does not represent an urgent or life-threatening complication.

C. Dark brown blood between the teeth: Dark brown blood suggests old, minimal bleeding and is not as concerning as active bright red bleeding. While it should be monitored, it is not the priority compared to signs of active hemorrhage.

D. Coffee-ground appearance of emesis: Coffee-ground emesis suggests the presence of digested blood, often from swallowed blood, and while concerning, it is a secondary finding. Frequent swallowing points more directly to active bleeding, which is more immediately life-threatening.

A. "Have you thought about moving to a new neighborhood?" B. "Let's discuss how you feel when you leave your house." C. “Tell me why you have developed an aversion to leaving your house." D. "Have you tried leaving your house just once per day?"

Correct Answer is B

Explanation

A. "Have you thought about moving to a new neighborhood?": This response may dismiss the client’s feelings and doesn't directly address the anxiety. It also suggests an unrealistic solution without understanding the root cause of the client's anxiety.

B. "Let's discuss how you feel when you leave your house.": This response encourages open communication and invites the client to express their feelings. It focuses on understanding the client’s anxiety, which is the first step in addressing and managing it.

C. "Tell me why you have developed an aversion to leaving your house.": While exploring the cause of the anxiety is important, this response may come across as judgmental and could make the client feel defensive. A more open and empathetic approach would help the client feel more comfortable discussing their feelings.

D. "Have you tried leaving your house just once per day?": While this might be helpful in a later stage of treatment, it doesn't address the underlying anxiety and could be perceived as a directive instead of an empathetic, open-ended question to explore the client's emotions and experiences.

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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

Correct Answer is A

Explanation

Correct Answer is B

Explanation

Study Resources

Company

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 collecting data from a child who is 1 hr postoperative following a tonsillectomy. Which of the following findings is the nurse's priority?

Correct Answer is A

Explanation

A nurse is talking with a client who reports that they have started feeling anxious every time they have to leave their house. Which of the following responses should the nurse make?

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.