A nurse is reinforcing teaching about advance directives with a client who has end-stage heart failure.
Which of the following statements by the client indicates an understanding of the teaching?
I should discuss this document with my family after I sign it.
I am not allowed to change my mind once I sign this document.
An atorney will need to notarize this document for it to be valid.
My partner needs to be present when I sign this document.
The Correct Answer is A
a. "I should discuss this document with my family after I sign it"
Advance directives are legal documents that allow an individual to specify the type of medical care they want to receive in case they become unable to make their own decisions. It is important for the client to discuss their wishes with their family members or loved ones so that they are aware of the client's desires and can act accordingly in case of an emergency.
b. "I am not allowed to change my mind once I sign this document" is incorrect. The client can change their mind about their advance directive at any time and for any reason. It is important for the client to review their advance directive periodically and make changes as necessary.
c. "An atorney will need to notarize this document for it to be valid" is also incorrect. While some states require advance directives to be notarized or witnessed, not all states do. It is important for the client to check with their state's laws regarding advance directives to ensure that their document is legally binding.
d. "My partner needs to be present when I sign this document" is not necessarily true. While it is recommended for the client to have a witness present when signing their advance directive, it does not have to be their partner. The witness should be someone who is not a family member, healthcare provider, or beneficiary of the client's estate.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This response acknowledges the client's request and demonstrates the nurse's willingness to accommodate her preferences. By offering to request a female nurse, the nurse shows respect for the client's autonomy and strives to meet her comfort and emotional needs.
The nurse should communicate this request to the appropriate individuals involved in the assignment process, such as the nurse manager or charge nurse, to ensure that the client's preferences are considered and addressed to the best of their ability.
Correct Answer is B
Explanation
To accurately assess the client's respirations, the nurse should observe the movements of the client's chest wall. This can be done by visually inspecting the rise and fall of the chest or by placing a hand on the client's chest to feel the movements. This allows the nurse to assess the depth, rhythm, and effort of the client's breathing. I
It is important to observe the client's respirations without informing them, as this may cause the client to alter their breathing pattern consciously.
Counting the client's respirations for a full minute (rather than 15 seconds) provides a more accurate measurement.
Placing the client in a supine position may not be necessary for assessing respirations, as it is primarily focused on observing the chest movements.
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