A nurse is caring for an older adult client who reports difficulty making health-related decisions. The client asks if it is possible to have a trusted friend make these decisions. Which of the following actions should the nurse take first?
Call the provider to discuss the client's preference with them and their family.
Explain to the client the process of designating another individual to make decisions for them.
Ask the client to discuss these preferences with their family first.
Ask the client if they would like their wishes documented in their health care records.
The Correct Answer is B
A. Call the provider to discuss the client's preference with them and their family: While involving the provider and family is important, the first step should be to educate the client about their options for designating a decision-maker.
B. Explain to the client the process of designating another individual to make decisions for them: The nurse should first provide information about how the client can designate a trusted individual to make decisions for them, such as through a durable power of attorney for healthcare. This allows the client to make an informed decision.
C. Ask the client to discuss these preferences with their family first: The nurse should first empower the client by explaining the process of designating a decision-maker. It is crucial to respect the client’s autonomy in making this decision before involving family.
D. Ask the client if they would like their wishes documented in their health care records: Before documenting, the nurse should ensure the client understands the process of assigning a decision-maker. Documentation is important, but the client needs to understand their options first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Stroking the lower abdomen: While this may sometimes stimulate the bladder, it is not the most effective technique for promoting urination. Techniques such as using warm water are more commonly recommended for stimulating urination.
B. Pouring warm water over the perineum: Pouring warm water over the perineum can help relax the pelvic muscles and stimulate the urge to urinate. This method is often used to assist with the initiation of urination, especially after catheter removal.
C. Performing Kegel exercises prior to urination: Kegel exercises strengthen the pelvic floor muscles and can improve urinary control over time, but they are not effective for immediately stimulating urination, especially in the postoperative period.
D. Leaning backward when sitting and attempting to urinate: Leaning backward may make it more difficult to urinate as it puts pressure on the bladder. The best position for urination is sitting upright with the feet flat on the floor, which allows relaxation of the pelvic muscles.
Correct Answer is A
Explanation
A. Use a standardized approach to giving the handoff report: Using a standardized approach, such as SBAR (Situation, Background, Assessment, Recommendation), ensures that all necessary information is communicated clearly and systematically.
B. Encourage the oncoming shift nurse to contact the provider with any questions: The primary focus of the handoff report should be to provide the oncoming nurse with all necessary information. Directly contacting the provider should not be a primary strategy.
C. Provide the handoff report at the nurses' station: Providing a report at the nurses' station may not be private or conducive to clear communication. It is better to conduct the report in a private area or at the client’s bedside to ensure confidentiality and clarity.
D. Record a verbal report on a recorder for the oncoming nurse to listen to: Recorded reports are not ideal for ensuring continuity of care because they lack the interactive aspect of handoff, such as clarifying questions or addressing concerns in real time.
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