An older adult man who manages all his personal affairs is admitted to a long-term care facility because of mobility problems related to rheumatoid arthritis. When the practical nurse (PN) presents the client with a blank advanced directives form, he explains that he is not dying and not cognitively impaired and informs he does not need to complete such a form. Which action is most important for the PN to take?
Explain that the form identifies his personal health care wishes for any future event.
Acknowledge the client's concerns and notify the healthcare provider of the client's wishes.
Ask a family member to describe the client's stated wishes regarding end-of-life care.
Document his refusal in his electronic medical record using his exact words.
The Correct Answer is A
A. Explaining that the advanced directives form helps identify personal health care wishes for any future health event is crucial because it clarifies the importance of the form in planning for future health care decisions, even if the client is not currently ill.
B. Acknowledging the client’s concerns and notifying the healthcare provider is less immediate and does not directly address the client's understanding of the advanced directives form.
C. Asking a family member about the client's wishes is unnecessary since the client has communicated his own wishes and concerns, and the focus should be on informing the client about the form.
D. Documenting the client’s refusal is important but secondary to educating the client on the purpose and importance of advanced directives.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Maternal hypotension is a significant adverse effect of epidural anesthesia that can lead to decreased uterine blood flow and fetal distress. Monitoring for hypotension is critical to ensure both maternal and fetal well-being.
B. While a vaginal hematoma is a potential complication, it is less immediately associated with the administration of epidural anesthesia compared to hypotension.
C. A continuous headache could indicate post-dural puncture but is less common and not the primary immediate concern compared to hypotension following an epidural.
D. Urinary retention can occur with epidural anesthesia, but maternal hypotension is a more urgent and significant immediate concern.
Correct Answer is C
Explanation
A. Body temperature is not directly relevant to the administration of zolpidem. Zolpidem is a sleep aid, so assessing body temperature is not necessary for this medication.
B. Bowel sounds are important for gastrointestinal assessments but are not related to the immediate considerations for zolpidem administration.
C. Assessing mental status is crucial before administering zolpidem because this medication can cause side effects like drowsiness, confusion, or impaired cognition. Ensuring the client’s mental status is appropriate helps prevent adverse effects.
D. Skin integrity is important for general health assessments but is not specifically relevant before administering a sleep aid like zolpidem.
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