The nurses talking with the spouse of an older adult client who has been diagnosed with dementia. The spouse states, "What will I do when my spouse cannot make decisions anymore?" Which of the following responses should the nurse make?

You have plenty of time to figure all of that out."

"Decisions will then be made for your spouse by the health care provider."

"Decisions should be made now for your spouse's future."

I can explain advance care planning to you."

Answer and Explanation

The Correct Answer is D

A. "You have plenty of time to figure all of that out." This response is not proactive and may not address the urgency of planning for future decisions. It is important to address these issues sooner rather than later.

B. "Decisions will then be made for your spouse by the health care provider." Healthcare providers will make decisions based on medical criteria and the patient's current condition, but they will typically follow the wishes expressed in advance directives or legal documents.

C. "Decisions should be made now for your spouse's future." This is a proactive approach, but it's important to involve the spouse in the decision-making process.

D. "I can explain advance care planning to you." This is the most appropriate response. Advance care planning involves discussing the client's wishes regarding their future care, including decisions about life-sustaining treatments. By explaining this process, the nurse can help the spouse prepare for a time when the client may be unable to make their own decisions.

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Correct Answer is C

Explanation

A. Assess the patient for physiological indicators of pain. While assessing physiological indicators (such as increased heart rate, blood pressure, or sweating) can provide clues about pain, these signs are not always reliable and can be influenced by other factors. This option does not directly address the patient’s verbal and non-verbal communication about their pain.

B. Observe the patient for behavior that is indicative of pain. Observing the patient’s behavior can be helpful, but it is not sufficient on its own. The patient’s cultural background may influence how they express pain, and relying solely on observation might lead to underestimating their pain.

C. Involve the patient in the pain assessment by asking more direct questions. This is the best option because it respects the patient’s cultural background and encourages a more accurate and detailed assessment of their pain. By asking direct questions, the nurse can gain a better understanding of the patient’s pain experience and provide appropriate care.

D. Compare the patient's facial expression to a FACES pain scale. Using a FACES pain scale can be useful, especially for patients who have difficulty verbalizing their pain. However, this option does not involve the patient in a more detailed discussion about their pain, which is crucial given the cultural context and the patient’s reluctance to openly admit to pain.

A. Clean skin using a side to side motion. B. Keep skin pinched while injecting medication. C. Apply firm pressure to the injection site. D. Insert the needle at a 45 or 90-degree angle.

Correct Answer is ["B","D"]

Explanation

A. Clean skin using a side to side motion. The skin should be cleaned in a circular motion from the center outward to reduce the risk of infection.

B. Keep skin pinched while injecting medication. Pinching the skin helps create a small "pocket" for the injection, making it easier to administer the medication subcutaneously.

C. Apply firm pressure to the injection site. Applying firm pressure is not recommended immediately after the injection as it can cause discomfort and does not affect absorption. Gentle pressure is usually recommended.

D. Insert the needle at a 45 or 90-degree angle. For subcutaneous injections, a 45-degree angle is often recommended for thinner individuals, while a 90-degree angle is appropriate for those with more tissue.

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The nurses talking with the spouse of an older adult client who has been diagnosed with dementia. The spouse states, "What will I do when my spouse cannot make decisions anymore?" Which of the following responses should the nurse make?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse is administering a subcutaneous injection to a client. Which of the following actions should the nurse take?

Correct Answer is ["B","D"]

Explanation

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