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.

Answer and Explanation

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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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.

A. The client reports that the restraints are too tight. B. The client is able to calmly follow commands. C. The client has been in the restraints for 4 hours. D. The client can explain the reasons for their behavior.

Correct Answer is B

Explanation

Choice A reason: Reporting tight restraints indicates discomfort, requiring adjustment, not discontinuation, which depends on behavioral safety. Calmly following commands justifies removal. Ignoring tightness risks injury or agitation, delaying safe restraint removal, critical for ethical care and preventing harm in clients with aggressive behavior.

Choice B reason: Calmly following commands indicates the client is no longer a danger, justifying restraint discontinuation per least-restrictive principles. This ensures safety and ethical care, critical for de-escalation, preventing prolonged restraint risks like injury, and supporting client dignity in acute behavioral management situations.

Choice C reason: Four hours in restraints triggers reassessment, not automatic discontinuation, which depends on behavior (e.g., calmly following commands). Assuming time alone justifies removal risks premature release if unsafe, potentially endangering staff or client, critical to avoid in managing aggressive behavior with mechanical restraints.

Choice D reason: Explaining behavior shows insight but doesn’t guarantee safety; calmly following commands is a stronger indicator for restraint removal. Assuming explanation suffices risks premature discontinuation, potentially compromising safety, critical for ensuring restraints are used only until the client is stable and non-threatening in acute settings.

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A nurse is documenting admission data for a client in an acute care facility. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a newly licensed nurse about advance directives. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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