A nurse is caring for a client who asks for information about advance directives and states, “I want to make sure my wishes are respected.” Which of the following responses should the nurse make?

I cannot be a witness to your advance directives in writing.

Your desire to have advance directives can be included in your medical record.

Your name can be removed from your advance directives at any time.

You must be at least 21 years old to complete advance directives.

Answer and Explanation

The Correct Answer is B

Choice A reason: Nurses can witness advance directives in many settings, depending on state laws, so stating they cannot is inaccurate. This response dismisses the client’s request without providing guidance, making it incorrect and unhelpful for addressing their wishes.
Choice B reason: Including the client’s desire for advance directives in the medical record ensures their wishes are documented and respected. This aligns with the Patient Self-Determination Act, facilitating care planning, making it the correct and supportive response.
Choice C reason: Stating the client’s name can be removed from advance directives is confusing, as directives are personal and revocable, not about name removal. This response is inaccurate and irrelevant to the client’s request, making it incorrect.
Choice D reason: There is no universal age requirement of 21 for advance directives; competent adults (typically 18+) can create them. This statement is incorrect and restrictive, misinforming the client about their rights, making it inappropriate.

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Correct Answer is B

Explanation

Choice A reason: Removing a thermometer for use on another client risks cross-contamination, as C. difficile spores are highly transmissible. Dedicated equipment is required to prevent spread, so this action is incorrect and violates infection control protocols.
Choice B reason: Wearing a gown during care prevents C. difficile spore transmission via contact, a key precaution for this infection. This aligns with CDC contact isolation guidelines, protecting staff and other patients, making it the correct action.
Choice C reason: Washing hands with alcohol-based cleaner is ineffective against C. difficile spores, which require soap and water to physically remove them. This action is incorrect and inadequate for infection control in this scenario.
Choice D reason: Wearing an N95 respirator is unnecessary, as C. difficile is not airborne. Contact precautions (gown, gloves) suffice, so this action is incorrect and overprotective, wasting resources without addressing the transmission mode.

A. I expect this medication to raise my blood pressure. B. I know it will be a couple of weeks before the medication helps me feel better. C. I should take this medication on an empty stomach. D. This medication will help me sleep if I take it in the morning.

Correct Answer is B

Explanation

Choice A reason: Amitriptyline, a tricyclic antidepressant, typically causes hypotension via alpha-adrenergic blockade, not hypertension. Expecting blood pressure elevation shows misunderstanding, as its cardiovascular effects require monitoring for orthostatic changes, not hypertensive risks, in depression treatment.
Choice B reason: Acknowledging a 2-4 week delay for amitriptyline’s effect shows understanding, as tricyclics increase synaptic serotonin and norepinephrine gradually, requiring neuroplastic changes for mood improvement. This reflects accurate knowledge of the drug’s onset, critical for managing expectations in depression therapy.
Choice C reason: Taking amitriptyline on an empty stomach is incorrect, as food reduces gastrointestinal side effects like nausea. Its absorption is unaffected by food, but taking it with meals improves tolerability, indicating a misunderstanding of administration guidelines for effective therapy.
Choice D reason: Morning dosing of amitriptyline is incorrect, as its sedative effects, via histamine blockade, are best utilized at bedtime to aid sleep. Morning use may cause daytime drowsiness, reducing adherence, indicating a misunderstanding of its pharmacological profile in depression management.

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A nurse is caring for a client who asks for information about advance directives and states, “I want to make sure my wishes are respected.” Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a Clostridium difficile infection. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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