The client diagnosed with diabetes mellitus type 2 wants to be an organ donor and asks the nurse, 'Which organs can I donate?' Which statement is the nurse's best response?
- A. It is wonderful you want to be an organ donor. Let's discuss this.
- B. You can donate any organ in your body, except the pancreas.
- C. You have to donate your body to science to be an organ donor.
- D. You cannot donate any organs, but you can donate some tissues.
Correct Answer: D
Rationale: Type 2 diabetes may contraindicate organ donation (e.g., kidneys, pancreas) due to vascular damage, but tissues (e.g., corneas) are often viable. Other responses are inaccurate.
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The nurse pronounced Dr. Smith's client to be clinically dead. Which should the nurse document on the client's chart?
- A. Brain scan indicates no brain wave activity, client pronounced deceased. Family refuses to talk with organ bank.
- B. Cardiac arrest noted, CPR initiated but unsuccessful. Pronounced dead.
- C. Pulse, respirations, and blood pressure absent at 0900, pronounced dead. Dr. Smith to sign death certificate.
- D. Client found without pulse, body cold to touch. Pronounced deceased at 0900.
Correct Answer: C
Rationale: Documentation should include objective findings (absent vital signs), time, and physician’s role, per legal standards. Brain scan or CPR details are specific, and cold body is insufficient.
Which situation would cause the nurse to question the validity of an AD when caring for the elderly client?
- A. The client's child insists the client make his or her own decisions.
- B. The nurse observes the wife making the husband sign the AD.
- C. A nurse encouraged the client to think about end-of-life decisions.
- D. A friend witnesses the client's signature on the AD form.
Correct Answer: B
Rationale: Coercion (wife forcing signature) invalidates an AD, as it must reflect the client’s voluntary wishes. Child insistence, nurse encouragement, or friend witnessing is acceptable.
The nurse is caring for a dying client and the family. The male client is Muslim. Which intervention should the nurse implement at the time of death?
- A. Allow the wife to stay in the room during postmortem care.
- B. Call the client's imam to perform last rites when the client dies.
- C. Place incense around the bed, but do not allow anyone to light it.
- D. Do not touch the body, and have the male family members perform care.
Correct Answer: D
Rationale: In Muslim tradition, family (often male) may perform postmortem care, respecting cultural practices. Wife’s presence, imam’s role, or incense are less specific.
The male client asks the nurse, 'Should I designate my wife as durable power of attorney for health care?' Which statement would be the nurse's best response?
- A. Yes, she should be because she is your next of kin.
- B. Most people don't allow their spouse to do this.
- C. Will your wife be able to support your wishes?
- D. Your children are probably the best ones for the job.
Correct Answer: C
Rationale: Choosing a proxy involves ensuring they’ll honor the client’s wishes, a key consideration. Kinship, rarity, or children are less relevant without this focus.
The nurse is teaching a class on chronic pain to new graduates. Which information is most important for the nurse to discuss?
- A. The nurse must believe the client's report of pain.
- B. Clients in chronic pain may not show objective signs.
- C. Alternate pain-control therapies are used for chronic pain.
- D. Referral to a pain clinic may be necessary.
Correct Answer: A
Rationale: Believing the client’s pain report is critical, as pain is subjective, per pain management guidelines. Objective signs, therapies, or referrals are secondary.