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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 charge nurse is teaching new staff members about factors that increase a client's risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence?
- A. A history of being in prison
- B. Experiencing delusions
- C. Male gender
- D. Previous violent behavior
Correct Answer: D
Rationale: The correct answer is D: Previous violent behavior. This is the best predictor of future violence because individuals who have a history of violent behavior are more likely to engage in violent acts in the future. This is based on the principle of past behavior being a strong indicator of future behavior.
A: A history of being in prison is not as strong a predictor as previous violent behavior because not all individuals who have been in prison exhibit violent tendencies.
B: Experiencing delusions may increase the risk of violence, but it is not as strong a predictor as previous violent behavior.
C: Male gender is a risk factor for violence, but it is not as specific or reliable as previous violent behavior.
Therefore, the most accurate predictor of future violence is an individual's history of previous violent behavior.
A case manager is meeting with a client who asks about using alternative therapies to manage her rheumatoid arthritis. Which of the following statements should the nurse make?
- A. We can review some information to help you select a safe alternative practitioner.
- B. If there are therapies available to you, your provider will tell you about them.
- C. Feel free to try whatever therapies that fit within your personal belief system.
- D. I'm sure you can find alternative remedies through an online support group.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Option A is the correct choice because it acknowledges the client's interest in alternative therapies and offers to review information to help select a safe practitioner. This response shows support for the client's autonomy and involves them in the decision-making process. It also ensures the client's safety by emphasizing the importance of selecting a reputable practitioner.
Incorrect Choices:
B: This choice assumes the provider will automatically inform the client about therapies, which may not always be the case. It does not actively involve the client in their care.
C: While it supports the client's autonomy, it lacks guidance on selecting a safe practitioner and may not prioritize the client's safety.
D: Suggesting online support groups for remedies may not ensure the safety or efficacy of the therapies, and it does not involve professional guidance.
A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure her blood pressure daily. Which of the following client statements indicates an understanding of the teaching?
- A. I will wait 15 minutes after drinking coffee to measure my blood pressure.
- B. I will measure my blood pressure while my arm is elevated above my heart.
- C. I should remove constrictive clothing prior to measuring my blood pressure.
- D. I should measure my blood pressure immediately after eating breakfast.
Correct Answer: C
Rationale: The correct answer is C: "I should remove constrictive clothing prior to measuring my blood pressure." Removing constrictive clothing ensures accurate blood pressure measurement by allowing the cuff to fit properly on the arm without any restrictions, leading to a more reliable reading. Choice A is incorrect as coffee can temporarily increase blood pressure. Choice B is incorrect because the arm should be at heart level, not elevated. Choice D is incorrect as blood pressure should be measured on an empty stomach for accuracy.
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.
A nurse is providing discharge teaching about home care of a surgical incision to a client who speaks a different language from the nurse. The nurse is communicating with the client using an interpreter. Which of the following actions should the nurse take?
- A. Speak slowly when talking to the interpreter.
- B. Pause in the middle of sentences.
- C. Speak directly to the client.
- D. Use gestures to convey meaning.
Correct Answer: C
Rationale: The correct answer is C: Speak directly to the client. This is crucial as it maintains a connection with the client, shows respect, and ensures understanding. Speaking to the interpreter directly can lead to misinterpretation. Speaking slowly (A) may come across as patronizing. Pausing in the middle of sentences (B) can disrupt communication flow. Using gestures (D) may help but should not replace direct verbal communication. The other choices are not as effective in ensuring clear communication and building trust with the client.