A nurse is caring for a client who has heart failure and is taking furosemide.
Which of the following statements by the client indicates a need for the nurse to intervene?

The nurse should determine if the client has prepared their advance directives, which are legal documents that specify the client’s wishes regarding medical care in case they become incapacitated. Advance directives can include a living will, a durable power of attorney for health care, or a do-not-resuscitate order. The nurse should respect the client’s autonomy and right to self-determination by asking about their advance directives and ensuring that they are documented and followed.

Choice A is wrong because the nurse should not delay the admission while the client fills out the facility’s advance directives form.

The client has the right to refuse or accept any treatment, including filling out an advance directives form.

The nurse should inform the client about the benefits of having advance directives, but should not coerce or pressure them to complete one.

Choice B is wrong because the nurse should not confirm with the client’s family that the consent form has been signed.

The consent form is a legal document that indicates that the client has given informed consent for the surgery, which means that they have received adequate information about the procedure, its risks and benefits, and alternative options.

The consent form should be signed by the client, unless they are a minor, mentally incompetent, or unable to communicate.

The nurse should verify that the consent form has been signed by the client or their legal representative before the surgery.

Choice C is wrong because the nurse should not explain to the client that signing the facility’s consent form means they cannot refuse care.

Signing the consent form does not waive the client’s right to withdraw consent at any time before or during the surgery.

The nurse should inform the client that they can change their mind and refuse care at any point, and that their decision will be respected and honored.

Place the newborn on a flat surface and clap hands loudly.

This action will elicit the Moro reflex, also known as the startle reflex, which is a normal, involuntary reaction that newborns and infants have when they’re startled. In response to the sound, the baby will throw back his or her head, extend out his or her arms and legs, cry, then pull the arms and legs back in.

Choice A is wrong because placing the newborn on their abdomen and observing the movement of their extremities will not trigger the Moro reflex.

This position may elicit other reflexes such as the crawling reflex or the tonic neck reflex.

Choice B is wrong because stroking the newborn’s cheek toward their mouth will not trigger the Moro reflex. This action will elicit the rooting reflex, which helps the baby find the breast or bottle to start feeding.

Choice C is wrong because stroking upward on the lateral aspect of the newborn’s foot will not trigger the Moro reflex. This action will elicit the Babinski reflex, which causes the big toe to extend upward and the other toes to fan out.