Nokea
The client asks the nurse, 'When will the durable power of attorney for health care take effect?' On which scientific rationale would the nurse base the response?
- A. It goes into effect when the client needs someone to make financial decisions.
- B. It will be effective when the client is under general anesthesia during surgery.
- C. The client must say it is all right for it to become effective and enforced.
- D. It becomes valid only when the clients cannot make their own decisions.
Correct Answer: D
Rationale: A durable power of attorney for health care activates when the client is incapacitated, per legal standards. Financial decisions, anesthesia, or client permission are incorrect triggers.
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The client has been declared brain dead and is an organ donor. The nurse is preparing the wife of the client to enter the room to say good-bye. Which information is most important for the nurse to discuss with the wife?
- A. Inform the wife the client will still be on the ventilator.
- B. Instruct the wife to only stay a few minutes at the bedside.
- C. Tell the wife it is all right to talk to the client.
- D. Allow another family member to go in with the wife.
Correct Answer: A
Rationale: Informing the wife about the ventilator prepares her for the client’s appearance, reducing distress, a priority for organ donors. Time limits, talking, or companions are secondary.
The nurse writes a client problem of 'spiritual distress' for the client who is dying. Which statement is an appropriate goal?
- A. The client will reconcile self and the higher power of his or her beliefs.
- B. The client will be able to express anger at the terminal diagnosis.
- C. The client will reconcile self to estranged members of the family.
- D. The client will have a dignified and pain-free death.
Correct Answer: A
Rationale: Spiritual distress goals focus on reconciling with beliefs or higher power, addressing the distress. Anger expression, family reconciliation, or pain-free death are separate issues.
The client with multiple sclerosis who is becoming very debilitated tells the home health nurse the Hemlock Society sent information on euthanasia. Which question should the nurse ask the client?
- A. Why did you get in touch with the Hemlock Society?
- B. Did you know this is an illegal organization?
- C. Who do you know who has committed suicide?
- D. What religious beliefs do you practice?
Correct Answer: A
Rationale: Asking why the client contacted the Hemlock Society explores their intent, guiding supportive care. Legality, suicide contacts, or religion are judgmental or irrelevant.
The nurse is caring for an 82-year-old female client who is crying and asking for her mother to come to see her. Which statement represents the ethical principle of nonmalfeasance?
- A. You must miss your mother very much. Can you tell me about her?
- B. You are 82 years old. Your mother is dead and can't come see you.
- C. Why do you need your mother? Can I get something for you?
- D. Your mother would not want you to worry. I will tell her you want to see her.
Correct Answer: A
Rationale: Nonmalfeasance (do no harm) involves empathetic engagement, like discussing the mother, avoiding emotional harm. Blunt truth, questioning needs, or false promises may distress.
Which tissue or organ can be repeatedly donated to clients needing a transplant?
- A. Skin.
- B. Bones.
- C. Kidneys.
- D. Bone marrow.
Correct Answer: D
Rationale: Bone marrow regenerates, allowing repeated donation. Skin, bones, and kidneys are limited or single-donation tissues/organs.