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 B
Explanation
A. Administering acetaminophen can help reduce fever and discomfort but does not directly address the respiratory distress indicated by tachypnea and stridor.
B. Monitoring the child's oxygen saturation level via pulse oximeter is essential to assess the severity of the respiratory distress. It provides critical information on the child's oxygenation status and helps guide further interventions.
C. Encouraging the child to drink adequate amounts of cool, clear liquids is beneficial for hydration but does not directly address the acute respiratory symptoms of irritability, tachypnea, and stridor.
D. Instructing the mother to play with the child for stimulation and distraction may help alleviate irritability but does not address the underlying respiratory distress, which requires immediate attention.
Correct Answer is C
Explanation
A. Moisture is important for skin assessments but does not directly affect the accuracy of a temporal artery temperature measurement.
B. Elasticity is part of skin turgor assessments and does not impact the accuracy of the temperature reading from a temporal artery scanner.
C. Assessing skin color is crucial because variations in skin color can affect the accuracy of the temporal artery temperature measurement. For accurate results, the skin should be clean and free of color alterations.
D. Checking the temperature of the skin is the outcome of the measurement process rather than a preliminary assessment for a temporal artery scanner.
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