A nurse is documenting admission data for a client in an acute care facility. Which of the following actions should the nurse take?
Begin charting with an evaluation of the data.
Document the client’s vital signs obtained by an assistive personnel.
Chart a summary of the data at the change of shift.
Note whether the client has a living will.
The Correct Answer is D
Choice A reason: Beginning charting with an evaluation skips the initial step of collecting and documenting raw data, such as health history and vital signs, which is critical for accurate admission records. This approach risks incomplete documentation, potentially leading to misinformed care plans and overlooking advance directives like a living will, essential for patient-centered care.
Choice B reason: Documenting vital signs from assistive personnel is routine but not the priority during admission. Noting a living will is more critical to ensure legal and ethical care preferences are addressed. Relying solely on delegated data risks missing comprehensive admission details, potentially compromising care coordination and patient autonomy in acute settings.
Choice C reason: Charting a summary at shift change is not specific to admission documentation, which requires detailed initial data, including advance directives like a living will. Summarizing later risks delaying critical information, such as legal preferences, potentially leading to care decisions that conflict with the patient’s wishes in acute care scenarios.
Choice D reason: Noting whether the client has a living will is a priority during admission to ensure advance directives are documented, guiding ethical and legal care decisions. This ensures patient autonomy, especially in acute settings where critical decisions arise. Addressing this upfront prevents oversight, aligning care with the client’s wishes and regulatory standards.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: A health care surrogate does not need to be a family member; clients can designate anyone they trust, such as a friend or attorney. This statement reflects a misunderstanding of advance directives, which prioritize client choice in appointing surrogates, making it incorrect.
Choice B reason: Providers cannot override advance directives unless legally challenged or deemed invalid. These documents legally bind providers to respect client wishes, such as refusing treatment. This statement misrepresents the legal authority of advance directives, making it an incorrect understanding.
Choice C reason: Providers do not choose health care surrogates; clients designate them in advance directives. If no surrogate is named, courts may appoint one. This statement incorrectly suggests provider authority over surrogate selection, indicating a misunderstanding of client autonomy in advance directives.
Choice D reason: Clients can resume control of health care decisions after regaining competency, as advance directives apply only during incapacity. This reflects correct understanding of the reversible nature of temporary incapacity, ensuring client autonomy is restored, making it the accurate statement.
Correct Answer is B
Explanation
Choice A reason: Strawberries are not commonly associated with latex-fruit syndrome, unlike bananas, which share proteins with latex, causing cross-sensitivity in latex-allergic individuals. Assuming strawberries risks missing dietary triggers, potentially causing allergic reactions, critical to avoid in ensuring safety for children with spina bifida and latex allergies.
Choice B reason: Bananas are linked to latex-fruit syndrome due to shared protein allergens, causing cross-sensitivity in latex-allergic individuals, like children with spina bifida. Assessing for banana allergy prevents anaphylaxis, critical for safety, guiding dietary restrictions, and ensuring comprehensive care in managing allergies in this population.
Choice C reason: Almonds are not typically linked to latex-fruit syndrome, unlike bananas, which are a common cross-sensitivity trigger in latex-allergic individuals. Assuming almonds risks overlooking true dietary risks, potentially leading to allergic reactions, critical to address in children with spina bifida and known latex allergies.
Choice D reason: Hazelnuts are not commonly associated with latex-fruit syndrome, unlike bananas, which pose a cross-sensitivity risk in latex-allergic children. Assuming hazelnuts risks missing key allergens, potentially causing allergic reactions, critical to prevent in ensuring safe dietary management for children with spina bifida and latex allergies.
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