A nurse is caring for a client who has not completed their advance directives. Which of the following actions should the nurse take?
Advise the family that a spiritual advisor will explain what life-sustaining measures are
Intervene if the client makes a health care decision the nurse does not agree with
Ensure the client has identified a health care surrogate.
Inform the client that once advance directives have been agreed upon, no changes can be implemented.
The Correct Answer is C
A. Advise the family that a spiritual advisor will explain what life-sustaining measures are: While spiritual advisors can provide support, the nurse should focus on ensuring the client understands their rights and options rather than delegating decision-making explanations to family or advisors. The client’s autonomy is the priority.
B. Intervene if the client makes a health care decision the nurse does not agree with: The nurse must respect the client’s autonomy and decisions regarding their care, even if they personally disagree. Intervening based on personal beliefs violates ethical and legal principles of patient rights.
C. Ensure the client has identified a health care surrogate: Helping the client designate a health care surrogate ensures that someone is authorized to make decisions if the client becomes incapacitated. This is a critical step in advance care planning and aligns with legal and ethical standards.
D. Inform the client that once advance directives have been agreed upon, no changes can be implemented: Advance directives can be updated or revoked at any time while the client is competent. Providing inaccurate information could limit the client’s rights and autonomy, so the nurse should clarify that changes are always possible.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Depression: Selegiline transdermal patches are indicated for the treatment of major depressive disorder. As a selective monoamine oxidase-B (MAO-B) inhibitor, it increases the availability of neurotransmitters such as dopamine, which can improve depressive symptoms in adults.
B. Anxiety: While selegiline may have indirect effects on mood, it is not primarily indicated for treating anxiety disorders. Anxiety may require other pharmacologic or therapeutic interventions specifically targeted to anxiety symptoms.
C. Tardive dyskinesia: Tardive dyskinesia is a movement disorder often associated with long-term antipsychotic use. Selegiline does not treat or prevent tardive dyskinesia; it is not indicated for movement disorder management in this context.
D. Bipolar mania: Selegiline is not indicated for the management of bipolar disorder or acute manic episodes. Treating mania typically involves mood stabilizers or antipsychotics rather than MAO-B inhibitors.
Correct Answer is A
Explanation
A. Recommend the client begin behavioral therapy: Behavioral therapy, particularly cognitive-behavioral therapy (CBT), is the first-line treatment for gambling disorder. It helps the client identify triggers, develop coping strategies, and change maladaptive behaviors associated with gambling.
B. Request a referral for electroconvulsive therapy: Electroconvulsive therapy (ECT) is not indicated for gambling disorder. ECT is primarily used for severe depression or treatment-resistant psychiatric conditions and does not address behavioral addictions.
C. Request a prescription for a stimulant medication: Stimulants are not recommended for treating gambling disorder and could worsen impulsivity or addictive behaviors. Pharmacologic therapy, when used, typically involves SSRIs or opioid antagonists for specific symptom management.
D. Inform the client that hospitalization is not used for the treatment of a gambling disorder: While outpatient therapy is common, some clients may require short-term hospitalization if comorbid psychiatric conditions or severe psychosocial crises are present. Blanket statements about hospitalization are not appropriate as part of individualized care planning.
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