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A nurse is caring for a client who is unconscious and whose partner is their health care surrogate. The partner wishes to discontinue the client's feeding tube, but another family member tells the nurse that they want the client to continue receiving treatment. Which of the following responses should the nurse make?
- A. We'll need to have the nursing supervisor review the client's advance directives.
- B. As the health care surrogate, the client's partner can make this decision.
- C. You should contact the provider about your wishes for your family member.
- D. You should speak with the facility's ethics committee about your concerns.
Correct Answer: B
Rationale: The correct answer is B: As the health care surrogate, the client's partner can make this decision. The rationale for this is that a health care surrogate is legally designated to make medical decisions on behalf of an incapacitated individual. In this case, since the client is unconscious, the partner's wishes as the surrogate should be followed.
Choice A is incorrect because involving the nursing supervisor to review advance directives is not necessary when a designated surrogate is involved. Choice C is incorrect as contacting the provider is not relevant when the surrogate has the legal authority to make decisions. Choice D is also incorrect as involving the ethics committee is not necessary when a surrogate has the authority to make decisions.
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A hospice nurse is caring for a client who has a terminal illness and reports severe pain. After the nurse administers the prescribed opioid and benzodiazepine, the client becomes somnolent and difficult to arouse. Which of the following actions should the nurse take?
- A. Withhold the benzodiazepine but continue the opioid.
- B. Administer the benzodiazepine but withhold the opioid.
- C. Continue the medication dosages that relieve the client's pain.
- D. Contact the provider about replacing the opioid with an NSAID.
Correct Answer: A
Rationale: The correct answer is A: Withhold the benzodiazepine but continue the opioid. Benzodiazepines can potentiate the sedative effects of opioids, leading to increased somnolence and difficulty arousing the client. By withholding the benzodiazepine, the nurse can help decrease the sedative effects, allowing the client to become more responsive while still receiving pain relief from the opioid. Continuing the opioid ensures that the client's pain is adequately managed. Administering the benzodiazepine alone (choice B) may exacerbate the sedative effects. Continuing the medication dosages (choice C) without adjusting the benzodiazepine dose may not address the sedation issue. Contacting the provider about replacing the opioid with an NSAID (choice D) is not indicated as opioids are typically the mainstay for managing severe pain in terminal illness.
A nurse is assessing a client who had a stroke 2 days ago. Which of the following findings should the nurse identify as a need for a referral to speech-language pathology?
- A. Diminished hand-to-mouth coordination
- B. Impaired voluntary cough
- C. Unilateral ptosis
- D. Altered level of consciousness
Correct Answer: B
Rationale: The correct answer is B: Impaired voluntary cough. Impaired voluntary cough in a client who had a stroke can indicate dysphagia, which is a common complication post-stroke. Referral to speech-language pathology is essential for assessing and managing dysphagia to prevent aspiration pneumonia and malnutrition. Diminished hand-to-mouth coordination (A) may indicate motor deficits but does not directly relate to speech and swallowing. Unilateral ptosis (C) is a drooping eyelid and is not typically a direct concern for speech-language pathology. Altered level of consciousness (D) may indicate neurological issues but does not specifically warrant a referral to speech-language pathology.
A nurse is caring for a client who has early-stage Alzheimer's disease. In which of the following actions is the nurse acting as a client advocate?
- A. Requesting a referral for the client to attend reminiscent therapy sessions
- B. Reorienting the client several times throughout the day
- C. Providing assistance for the client when ambulating down the hall
- D. Performing an updated cognitive assessment on the client
Correct Answer: A
Rationale: Requesting reminiscent therapy promotes the client's cognitive function and dignity, aligning with advocacy by prioritizing their best interests.
A nurse is providing teaching to a client about advance directive. Which of the following statements by the client indicates an understanding of the teaching?
- A. Once I sign my living will, a family member must co-sign it.
- B. My durable power of attorney for health care is part of my advance directives.
- C. I will wait until I have a serious health problem to sign my advance directives.
- D. My doctor will need to provide approval for the decisions outlined in my living will.
Correct Answer: B
Rationale: The correct answer is B: My durable power of attorney for health care is part of my advance directives. This statement indicates understanding because a durable power of attorney for health care is a legal document that allows an individual to appoint someone to make healthcare decisions on their behalf if they are unable to do so. Advance directives include both living wills and durable powers of attorney for health care. Therefore, acknowledging that the durable power of attorney for health care is part of advance directives demonstrates comprehension of the topic.
Incorrect Answers:
A: Once I sign my living will, a family member must co-sign it - This is incorrect as a living will does not require a family member to co-sign.
C: I will wait until I have a serious health problem to sign my advance directives - This is incorrect as advance directives should be completed before a health crisis occurs.
D: My doctor will need to provide approval for the decisions outlined in my living will - This is incorrect as the decisions in a living will are made
A nurse is providing teaching to assistive personnel about the application of wrist restraints to a client. Which of the following instructions should the nurse include in the teaching?
- A. Secure the client's restraints with a square knot.
- B. Attach the restraints to the fixed portion of the frame of the client's bed.
- C. Remove the client's restraints every 2 hr.
- D. Allow 1 fingerbreadth between the restraint and the client's wrists.
Correct Answer: C
Rationale: The correct answer is C: Remove the client's restraints every 2 hr. This instruction is crucial to prevent complications such as skin breakdown, circulation impairment, and emotional distress. Restraints should be released every 2 hours to assess the client's condition, provide necessary care, and ensure safety. This practice also promotes mobility and prevents long-term consequences of prolonged restraint use.
Explanation for other choices:
A: Secure the client's restraints with a square knot - Incorrect. Restraints should be secured with a quick-release knot to ensure quick removal in case of an emergency.
B: Attach the restraints to the fixed portion of the frame of the client's bed - Incorrect. Restraints should be attached to the movable portion of the bed frame to allow for adjustments and prevent harm.
D: Allow 1 fingerbreadth between the restraint and the client's wrists - Incorrect. Restraints should be snug but not too tight to avoid injury or discomfort.