Which information should the practical nurse (PN) collect during admission assessment of a terminally ill client to an acute care facility?
Name of funeral home to contact.
Contact information for client's next of kin.
Health care proxy documentation
Client's wishes regarding organ donation.
The Correct Answer is C
The correct answer is choice C. Health care proxy documentation.
Choice A rationale:
The name of the funeral home to contact is not immediately relevant during the admission assessment of a terminally ill client. This information can be collected later as part of end-of-life planning but is not critical for the initial assessment.
Choice B rationale:
While the contact information for the client’s next of kin is important for communication and support, it is not as crucial as health care proxy documentation for making immediate healthcare decisions.
Choice C rationale:
Health care proxy documentation is essential because it designates someone to make healthcare decisions on behalf of the client if they become unable to do so themselves. This ensures that the client’s healthcare preferences and decisions are respected and followed by the healthcare team.
Choice D rationale:
The client’s wishes regarding organ donation are important but are often included in the health care proxy documentation. This information is not as immediately critical as the health care proxy documentation during the admission assessment.
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Related Questions
Correct Answer is B
Explanation
This is the best initial intervention for the PN to implement because it promotes comfort, relaxation, and circulation for the client. A back rub can also reduce anxiety and muscle tension, which can interfere with sleep. The PN should use non-pharmacological methods to facilitate sleep before resorting to medication.
A. Offering the client a prescribed sleep medication is not the best initial intervention because it may have side effects or interactions with other drugs. The PN should assess the client's need for medication and use it as a last resort.
C. Administering an as-needed (PRN) prescription for pain is not the best initial intervention because it may not address the cause of the client's difficulty in sleeping. The PN should assess the client's pain level and use other methods to relieve pain before giving medication.
D. Providing a cup of hot chocolate at bedtime is not the best initial intervention because it may contain caffeine, which can stimulate the central nervous system and keep the client awake. The PN should avoid giving caffeinated beverages to the client before bedtime.
Correct Answer is D
Explanation
This is the best intervention for the PN to implement because it monitors the client's fluid status and helps detect fluid overload, which can cause hypertension and neurological changes. The PN should weigh the client at the same time, on the same scale, and with the same clothing every day.
A. Using a cushion when sitting is not a priority intervention for this client and may not address the BP or mental status issues.
B. Performing range of motion exercises is not a priority intervention for this client and may not address the BP or mental status issues.
C. Documenting abdominal girth is not a priority intervention for this client and may not be an accurate indicator of fluid status.
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