A nurse is caring for a client who is comatose and has advance directives that indicate the client does not want life-sustaining measures. The client's family wants the client to have life-sustaining measures. Which of the following actions should the nurse take?
Arrange for an ethics committee meeting to address the family's concerns.
Complete an incident report.
Support the family's decision and initiate life-sustaining measures.
Encourage the family to contact an attorney.
The Correct Answer is A
A. Arrange for an ethics committee meeting to address the family's concerns. An ethics committee can provide guidance in situations where there is conflict between advance directives and family wishes. This supports ethical decision-making while honoring the client’s autonomy and legal rights.
B. Complete an incident report. An incident report is used for errors or unusual events, not ethical dilemmas or conflicts over advance directives. It is not appropriate in this scenario.
C. Support the family's decision and initiate life-sustaining measures. The nurse is legally and ethically bound to follow the client’s advance directives, not the family’s wishes, especially when the client’s decisions are documented and clear.
D. Encourage the family to contact an attorney. While families have legal rights, referring them directly to an attorney does not address the immediate ethical issue or facilitate collaborative resolution in the care setting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "After 5 to 10 minutes when the breast is emptied, my baby should be removed from the breast." The breast is rarely fully emptied during a feeding. Infants should be allowed to feed on one side until they naturally release it, ensuring they receive the nutrient-rich hindmilk.
B. "Manually expressing my milk will decrease my milk supply." Manual expression, like breastfeeding, stimulates milk production. Regularly removing milk from the breasts actually helps maintain or increase supply, especially during periods of engorgement or separation.
C. “My baby should always start on the same breast when feeding.” Alternating the starting breast with each feeding ensures even stimulation and drainage of both breasts. Always starting on the same side could lead to engorgement or reduced supply in the unused breast.
D. “The more my baby is at the breast sucking the more milk I will produce.” Breast milk production is based on a supply and demand mechanism. The more frequently and effectively the baby nurses, the more milk the body is signaled to produce.
Correct Answer is D
Explanation
A. Contraction intensity increased by ambulation. This finding is typical of true labor, as walking or changing positions usually causes contractions to increase in strength, duration, and frequency. In contrast, false labor contractions often subside with rest or activity changes and do not intensify with movement.
B. Slow change in dilation and effacement. Any change in cervical dilation or effacement, even if slow, is more consistent with true labor. False labor does not produce any significant cervical change, and the cervix remains closed or minimally altered with time or contractions.
C. Presence of bloody show. Bloody show is the expulsion of the mucus plug mixed with blood, a common sign of cervical softening and dilation. This is a key indicator of true labor, as it reflects actual physical changes in preparation for delivery.
D. Intermittent painless contractions. These contractions, also called Braxton Hicks contractions, are a hallmark of false labor. They are usually irregular, mild, and do not lead to cervical changes. They often resolve with hydration, rest, or position changes and are considered a normal part of the body's preparation for labor, not the onset of true labor.
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