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A nurse is admitting a client who is hesitant to create advance directives due to concerns about affording legal representation. Which of the following statements should the nurse make?
- A. We can initiate medical care until you get legal assistance in preparing your advance directives.
- B. Advance directives can be signed without legal representation.
- C. Advance directives can be a verbal agreement between you and your provider until legal review can be obtained.
- D. A social worker will assist you to find affordable legal representation.
Correct Answer: B
Rationale: Correct Answer: B - Advance directives can be signed without legal representation.
Rationale: Advance directives do not require legal representation to be valid. They are legal documents that outline a person's healthcare wishes in case they are unable to communicate. These documents can be completed by the individual themselves, without the need for a lawyer. By choosing option B, the nurse can provide accurate information and alleviate the client's concerns about the cost of legal representation.
Incorrect Choices:
A: Initiating medical care without advance directives may not align with the client's wishes.
C: Verbal agreements are not legally binding for advance directives.
D: While a social worker can provide resources, legal representation may not be necessary for advance directives.
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A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse identify as tertiary prevention?
- A. Using an electronic messaging system to remind clients when to take medications.
- B. Educating clients about contraindications to specific immunizations.
- C. Helping clients understand health screenings covered by their insurance plans.
- D. Providing clients with information about the benefits of exercise.
Correct Answer: A
Rationale: The correct answer is A because using an electronic messaging system to remind clients when to take medications is an example of tertiary prevention. Tertiary prevention focuses on managing and minimizing the impact of a disease or condition to prevent complications or further deterioration. By reminding clients to take their medications, the nurse is helping to prevent disease progression and improve health outcomes.
Choice B, educating clients about contraindications to specific immunizations, is an example of secondary prevention as it aims to detect and treat a disease early to prevent complications.
Choice C, helping clients understand health screenings covered by their insurance plans, is an example of primary prevention as it aims to prevent the onset of a disease or condition.
Choice D, providing clients with information about the benefits of exercise, is also an example of primary prevention as it focuses on promoting overall health and preventing the development of diseases.
A nurse is planning care for a client who has a prescription for a bowel-training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care?
- A. Increase the amount of refined grains in the client's diet.
- B. Provide the client with a cold drink prior to defecation.
- C. Administer a cathartic suppository 30 min prior to scheduled defecation times
- D. Encourage a maximum fluid intake of 1,500 mL per day.
Correct Answer: C
Rationale: The correct answer is C: Administer a cathartic suppository 30 min prior to scheduled defecation times. This action helps stimulate bowel movement in clients with spinal cord injuries by promoting peristalsis and aiding in bowel evacuation. Increasing refined grains (choice A) may not directly address the bowel-training program. Providing a cold drink (choice B) may not have a significant impact on bowel movements. Restricting fluid intake to 1,500 mL per day (choice D) can lead to dehydration and worsen constipation.
A nurse is providing preoperative teaching to a client about promoting circulation during the postoperative period. Which of the following instructions should the nurse include?
- A. Remain on bed rest for 24 hours following the procedure.
- B. Participate in range-of-motion exercises.
- C. Use an incentive spirometer every 4 hours.
- D. Place a pillow under your knees while in bed.
Correct Answer: B
Rationale: The correct answer is B: Participate in range-of-motion exercises. Range-of-motion exercises help prevent immobility-related complications such as blood clots and promote circulation postoperatively. This helps prevent complications like deep vein thrombosis. Choices A, C, and D are incorrect. Remaining on bed rest for 24 hours can increase the risk of blood clots. Using an incentive spirometer every 4 hours helps with lung function, not circulation. Placing a pillow under the knees only helps with comfort, not circulation.
While performing a routine assessment, a nurse notices fraying on the electrical cord of a client's continuous passive motion (CPM) device. Which of the following actions should the nurse take first?
- A. Initiate a requisition for a replacement CPM device.
- B. Report the defect to the equipment maintenance staff.
- C. Remove the device from the room.
- D. Ensure the device inspection sticker is current.
Correct Answer: C
Rationale: The correct action the nurse should take first is to remove the device from the room (Choice C). This is crucial because a frayed electrical cord poses a significant safety risk, potentially leading to electric shock or fire hazard. By removing the device from the room, the nurse ensures that the client and others are not exposed to the danger posed by the damaged cord. Initiating a requisition for a replacement device (Choice A) can be done after ensuring immediate safety. Reporting the defect to equipment maintenance staff (Choice B) is important, but it is secondary to removing the device from the room. Ensuring the device inspection sticker is current (Choice D) is not the priority when there is a clear safety issue present.
A nurse is reinforcing teaching about advance directives with a client who has end-stage renal disease. Which of the following client statements indicates an understanding of the teaching?
- A. I know that I can change my advance directives if needed in the future.
- B. My healthcare proxy will make decisions as soon as I sign the power of attorney.
- C. My family can overrule the decisions made by my healthcare proxy.
- D. Advance directives from one state are valid in any other state.
Correct Answer: A
Rationale: Rationale: Option A is correct because it shows the client understands that advance directives can be modified. This is crucial as preferences may change over time. Option B is incorrect as the healthcare proxy only makes decisions when the client cannot. Option C is incorrect as the healthcare proxy's decisions are legally binding. Option D is incorrect because advance directives must comply with state laws and may not be universally recognized.