A nurse provides care to an older hospitalized client who is newly admitted for advanced liver failure. The client states, "I've told my doctor to let me die if my heart stops beating or if I quit breathing. I do not want to be revived." To best ensure the client's request is honored, which of the following should the nurse do?
Assure the client that their end-of-life wishes are followed right away.
Check the medical record for a DNR order.
Ask the client if they have a healthcare proxy who can speak for them if needed.
Verify a signed copy of the advance directives in the medical record.
The Correct Answer is B
Choice A reason : While it is important to assure the client, the nurse must first verify that there is a formal DNR order in place to legally honor the client's wishes¹².
Choice B reason : Checking for a DNR order in the medical record is the correct action to ensure that the client's wishes regarding resuscitation are documented and will be followed by all healthcare providers¹².
Choice C reason : Asking about a healthcare proxy is important, but it is secondary to confirming that the client's wishes are documented in the medical record through a DNR order or advance directives¹².
Choice D reason : Verifying a signed copy of the advance directives is crucial, but the immediate step is to check for a DNR order, which is specifically related to the client's request not to be resuscitated¹².
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A reason : Pupillary changes, such as unequal pupil sizes or a sluggish reaction to light, can be a sign of increased ICP. The cranial nerves that control the pupils may be compressed due to the swelling of the brain, leading to these changes¹.
Choice B reason : Disorientation, including confusion and changes in alertness, can occur with increased ICP as the pressure affects the brain's ability to process information and maintain consciousness².
Choice C reason : Headache is a common symptom of increased ICP. It can be severe and persistent due to the pressure exerted on the meninges and blood vessels within the brain³.
Choice D reason : Slurred speech may result from increased ICP if the areas of the brain responsible for speech and muscle control are affected by the pressure².
Choice E reason : Neck pain and stiffness, particularly when trying to flex the neck forward, can be indicative of meningeal irritation, which can be associated with increased ICP⁴.
Correct Answer is B
Explanation
Choice A reason : Heat intolerance is not a symptom associated with myxedema coma. Instead, patients with myxedema coma typically present with cold intolerance due to decreased metabolic rate and reduced heat production as a result of hypothyroidism¹.
Choice B reason : Facial edema, particularly around the eyes, is a characteristic finding in myxedema coma. This condition results from severe hypothyroidism, which can cause mucopolysaccharide deposition in the skin, leading to non-pitting edema¹.
Choice C reason : Tachycardia is not expected in myxedema coma; rather, bradycardia is more common due to the reduced metabolic demands of the body in the hypothyroid state¹.
Choice D reason : Diarrhea is not typically a symptom of myxedema coma. Patients are more likely to experience constipation due to slowed gastrointestinal motility in the context of hypothyroidism¹.
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