A nurse is teaching participants at a community center about advance directives. Which of the following information should the nurse include in the teaching?
Assigning a health care surrogate requires legal consultation.
A health care surrogate makes health care decisions when the client is no longer able.
Advance directives cannot be changed once implemented.
Advance directives are only valid in the state where they are created.
The Correct Answer is B
Choice A reason: Assigning a health care surrogate does not always require legal consultation, as forms are often available without attorney involvement. While legal advice can clarify complex cases, it is not mandatory, making this statement misleading and incorrect for general advance directive education.
Choice B reason: A health care surrogate makes decisions when the client is incapacitated, as specified in advance directives. This ensures the client’s wishes are followed, aligning with the purpose of surrogacy in healthcare planning, making it accurate and essential information for the teaching session.
Choice C reason: Advance directives can be changed at any time by a competent client, provided the changes are documented and communicated. Stating they cannot be changed is incorrect, as flexibility is a key feature, making this misinformation inappropriate for teaching.
Choice D reason: Advance directives are generally honored across states, though specific requirements may vary. Stating they are only valid in one state is overly restrictive and incorrect, as reciprocity is common, making this an inaccurate point for advance directive education.
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Correct Answer is C
Explanation
Choice A reason: Raising the head of the bed during transfer does not prioritize ergonomic principles. It may strain the nurse’s back or misalign the client, increasing injury risk. Ergonomics focuses on neutral spine alignment and mechanical aids to reduce physical strain during client transfers.
Choice B reason: Placing pillows under the head is a comfort measure, not an ergonomic principle. Ergonomics emphasizes reducing musculoskeletal strain through proper mechanics or devices. Pillows do not directly prevent nurse injuries, unlike transfer devices that minimize physical effort during client movement.
Choice C reason: Using a lateral transfer device, like a slide board, aligns with ergonomic principles by reducing manual lifting and spinal strain. It prevents back injuries, ensuring safe client transfer. This evidence-based practice supports occupational health guidelines, minimizing musculoskeletal risks for nurses during patient handling.
Choice D reason: Standing close during ambulation ensures client stability but is not a primary ergonomic principle. Ergonomics focuses on equipment and mechanics to reduce strain, not proximity, which addresses patient safety more than nurse injury prevention during transfers or repositioning tasks.
Correct Answer is D
Explanation
Choice A reason: Avoiding reading for 3 months is not a standard instruction post-retinal detachment surgery. Reading may be restricted temporarily (e.g., 1-2 weeks) if specific positioning is required, but 3 months is excessive. Patients are typically advised to avoid straining, not reading, making this instruction incorrect.
Choice B reason: Bending at the waist increases intraocular pressure, which can disrupt retinal repair and lead to re-detachment. Patients should bend at the knees to avoid straining the eye. This instruction is harmful and contraindicated, as it risks complications in the healing retina.
Choice C reason: Lifting objects up to 50 pounds is dangerous post-retinal surgery, as heavy lifting increases intraocular pressure, risking re-detachment. Guidelines typically restrict lifting to 10-20 pounds during recovery (4-6 weeks). This instruction is incorrect, as it poses a significant risk to surgical outcomes.
Choice D reason: Taking a stool softener daily prevents straining during bowel movements, which can increase intraocular pressure and disrupt retinal healing. Constipation is a concern post-surgery due to immobility or pain medications, and stool softeners ensure safe bowel movements, making this the correct instruction.
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