A nurse is caring for a client who has named a person to serve as his health care proxy. The client talks about this type of advance directives. Which of the following statements by the client indicates a need for clarification?

"I can change who I designate as my health care proxy at any time."

"I have to choose a family member as my health proxy."

"I become incapacitated, end-of-life choices will be made by my proxy"

"The health care proxy does not go into effect until 1 am incapable of making decisions,"

Answer and Explanation

The Correct Answer is B

A. "I can change who I designate as my health care proxy at any time": This statement is correct. Clients have the right to change their designated health care proxy at any time as long as they are competent to do so. It's important for clients to know that they have flexibility in selecting their proxy based on their preferences and trust in the individual's ability to represent their wishes.
B. "I have to choose a family member as my health proxy": This statement requires clarification. While many clients may choose a family member as their health care proxy, it is not a requirement. Clients have the autonomy to choose any individual they trust to make medical decisions on their behalf, whether it's a family member, friend, or even a legal representative. It's crucial to ensure that the chosen proxy understands the client's wishes and is willing and able to advocate for them.
C. "If I become incapacitated, end-of-life choices will be made by my proxy": This statement is accurate. A health care proxy is designated to make medical decisions on behalf of the client if they become incapacitated and are unable to make decisions for themselves. The proxy is responsible for advocating for the client's wishes, including end-of-life preferences, if outlined in the advance directive or communicated to the proxy beforehand.
D. "The health care proxy does not go into effect until I am incapable of making decisions": This statement is generally correct. Health care proxies typically become active only when the client is deemed incapacitated and unable to make decisions for themselves, as determined by a healthcare provider. However, the specifics may vary depending on state laws and the language of the advance directive document. It's essential for clients to understand when the proxy's authority begins and how it transitions based on their capacity to make decisions.

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Correct Answer is C, B, A, D

Explanation

Inspection:This is the first step because it allows the nurse to gather information through observation without causing any discomfort to the child. It involves looking at the child's abdomen for any visible abnormalities like distension, asymmetry, masses, or discoloration.

Auscultation:After inspection, the nurse listens to the bowel sounds using a stethoscope. This helps assess peristalsis (movement of food through the intestines) and identify potential problems like bowel obstruction or decreased motility.

Superficial Palpation:This gentle palpation helps assess muscle tone, tenderness, and masses. It's performed after auscultation to avoid altering bowel sounds. Since children are often apprehensive about abdominal exams, starting with a gentler touch can help them feel more comfortable.

Deep Palpation (if necessary):Deep palpation is reserved for last as it can be more uncomfortable for the child. It's used to assess for organomegaly (enlarged organs) or masses that may not be palpable with superficial palpation. It's only performed if there are indications from the first three steps.

Here's a breakdown of why this order is important:

Minimize Discomfort:Starting with non-invasive methods like inspection and auscultation helps establish trust and reduces anxiety in the child, making the overall assessment more cooperative.

Maintain Baseline Bowel Sounds:Palpation can alter bowel sounds, so it's important to listen to them first to get an accurate baseline.

Gradual Progression:Moving from gentle to deeper palpation allows the child to adjust to the sensation and helps the nurse identify potential areas of tenderness before applying deeper pressure.

A. "There is no way to predict how long it will last in each individual client B. "It occurs during the first trimester and near the end of the pregnancy." C. "In most cases it only lasts until the 12th week, but it will continue if you have poor bladder tone." D. "It’s a minor inconvenience, which you should ignore. "

Correct Answer is B

Explanation

A. "There is no way to predict how long it will last in each individual client." This response acknowledges the variability among individuals but does not provide specific information about urinary frequency during pregnancy. While it's true that the duration of urinary frequency can vary from person to person, the response lacks guidance or reassurance for the client.
B. "It occurs during the first trimester and near the end of the pregnancy." This response correctly identifies the pattern of urinary frequency during pregnancy. Urinary frequency is common during the first trimester due to hormonal changes and the growing uterus pressing on the bladder. It may also occur near the end of pregnancy as the fetus descends into the pelvis, putting pressure on the bladder again.
C. "In most cases it only lasts until the 12th week, but it will continue if you have poor bladder tone." This response suggests that urinary frequency typically resolves by the 12th week of pregnancy but may persist if the client has poor bladder tone. While urinary frequency may improve for some women after the first trimester, attributing its continuation solely to poor bladder tone oversimplifies the issue.
D. "It’s a minor inconvenience, which you should ignore." This response minimizes the client's concerns and does not provide helpful information about urinary frequency during pregnancy. Urinary frequency can be distressing for some pregnant individuals and should not be dismissed as a minor inconvenience.

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A nurse is caring for a client who has named a person to serve as his health care proxy. The client talks about this type of advance directives. Which of the following statements by the client indicates a need for clarification?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Correct Answer is C, B, A, D

Explanation

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Correct Answer is B

Explanation

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