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An adult client who has a severe neurocognitive impairment is scheduled for gallbladder surgery. With regard to the informed consent, which should the nurse implement first to facilitate the scheduled surgery?
- A. Check for the identity of the client's legal guardian.
- B. Inform the legal guardian about advance directives.
- C. Arrange for the surgeon to provide informed consent.
- D. Ensure that the legal guardian signed the informed consent.
Correct Answer: A
Rationale: A mentally impaired client is not competent to sign an informed consent, so the nurse should first verify the identity of the client's legal guardian. This action fulfills part of the nurse's duty in informed consent, helps avoid improperly signed documents, and directs the surgeon to the legal representatives of the client's interests. The client and/or legal guardian is asked about the existence of an advance directive at the time of admission, so this should have already been done, making option 2 incorrect. The surgeon is responsible for obtaining the informed consent, but based on the options provided, option 3 is not the first nursing action. Likewise, option 4 is not the first action; the nurse checks identity of the legal guardian first.
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The nurse performing an admission assessment notes that a client has been prescribed metoclopramide for a prolonged period. The nurse should immediately call the primary health care provider if which signs/symptoms were then noted by the nurse?
- A. Dry mouth
- B. Anxiety or irritability
- C. Excessive drowsiness
- D. Uncontrolled rhythmic movements of the face or limbs
Correct Answer: D
Rationale: If the client experiences tardive dyskinesia (rhythmic movements of the face or limbs), the nurse should call the primary health care provider because these adverse effects may be irreversible. The medication would be discontinued, and no further doses should be given by the nurse. Anxiety, irritability, and dry mouth are mild side effects that do not harm the client.
The nurse is planning a discharge teaching plan for a client who sustained a spinal cord injury. To provide for a safe environment regarding home care, which option should be the priority in the discharge teaching plan?
- A. Assisting the client to deal with long-term care placement
- B. Including the client's significant others in the teaching session
- C. Following up on laboratory and diagnostic tests that were prescribed
- D. Including information the primary health care provider has indicated
Correct Answer: B
Rationale: Involving the client's significant others in discharge teaching is a priority in planning for the client with a spinal cord injury. The client will need the support of the significant others. Knowledge and understanding of what to expect will help both the client and significant others deal with the client's limitations. Long-term placement is not the only option for a client with a spinal cord injury. Laboratory and diagnostic testing are not priority discharge instructions for this client. A primary health care provider's prescription is not necessary for discharge planning and teaching; this is an independent nursing action.
The nurse manager is planning to implement needed changes in the method of the documentation system for the nursing unit. Which should be the initial step in the process of change for the nurse manager?
- A. Plan strategies to implement the change.
- B. Set goals and priorities regarding the change process.
- C. Identify the inefficiency that needs improvement or correction.
- D. Identify potential solutions and strategies for the change process.
Correct Answer: C
Rationale: When beginning the change process, the nurse should identify and define the problem that needs improvement or correction. This important first step can prevent many future problems because, if the problem is not correctly identified, a plan for change may be aimed at the wrong problem. This is followed by goal setting, prioritizing, and identifying potential solutions and strategies to implement the change.
A client asks the nurse to act as a witness for an advance directive. Which is the best intervention for the nurse to implement?
- A. Suggest the nurse manager as a witness.
- B. Agree to sign the document as a witness.
- C. Notify the provider of the client's request.
- D. Help the client find an unrelated third party.
Correct Answer: D
Rationale: An advance directive addresses the withdrawal or withholding of life-sustaining interventions that can prolong life and identifies the person who will make care decisions if the client becomes incompetent. Two people unrelated to the client witness the client's signature and then sign the document signifying that the client signed the advance directive authentically. Nurses or employees of a facility in which the client is receiving care and beneficiaries of the client should not serve as a witness because of conflict of interest concerns. There is no reason to call the provider unless the absence of the advance directive interferes with client care.
A child diagnosed with a malignant brain tumor is admitted for removal of the tumor. The nurse should include which action in the plan of care to ensure a safe environment for the child?
- A. Initiating seizure precautions
- B. Using a wheelchair for out-of-bed activities
- C. Assisting the child with ambulation at all times
- D. Minimizing contact with other children on the nursing unit
Correct Answer: A
Rationale: Seizure precautions should be implemented for any child with a brain tumor, both preoperatively and postoperatively. Options 2 and 3 are not required unless functional deficits exist. Based on the child's diagnosis, option 4 is not necessary.