Nokea
Upon completing the admission documents, the nurse learns that the 87 year-old client does not have an advance directive. What action should the nurse take?
- A. Record the information on the chart
- B. Give information about advance directives
- C. Assume that this client wishes a full code
- D. Refer this issue to the unit secretary
Correct Answer: B
Rationale: For each admission, nurses should request a copy of the current advance directive. If there is none, the nurse must offer information about what an advance directive implies. It is then the client's choice to sign it.
You may also like to solve these questions
The nurse is caring for a client with a history of polycystic kidney disease.
- A. Which symptom is expected in a client with polycystic kidney disease?
- B. Chest pain and dyspnea.
- C. Flank pain and hematuria.
- D. Weight loss and fever.
- E. Numbness in the extremities.
Correct Answer: B
Rationale: Flank pain and hematuria are common in polycystic kidney disease due to cyst pressure and rupture. Chest pain, weight loss, and numbness are unrelated.
A patient is admitted to the surgical unit with a diagnosis of rule out inTest inal obstruction.
- A. In which position should the nurse place the patient during insertion of a Salem sump NG tube?
- B. Head of bed elevated 30°-45°.
- C. Head of bed elevated 60°-90°.
- D. Side-lying with head elevated 15°.
- E. Lying flat with head turned to the left side.
Correct Answer: B
Rationale: Elevating the head of the bed to 60°-90° facilitates swallowing and movement of the NG tube through the gastroinTest inal tract, reducing the risk of aspiration and improving patient comfort during insertion. Other positions do not optimize swallowing or tube passage as effectively.
A client with a diagnosis of a ruptured lumbar disc.
The nurse should anticipate which of the following in assessing a client with a diagnosis of a ruptured lumbar disc?
- A. Sensation loss in an upper extremity.
- B. Clonic jerks in the affected foot.
- C. Paresthesia in the affected leg.
- D. Chorea in the upper and lower extremities.
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) results from cervical lesions (2) can occur in a person who has been paralyzed from a spinal cord injury (3) correct-lumbar lesions can cause paresthesia, pain, muscle weakness, and atrophy in the lower extremities (4) is a sign of Huntington chorea, resulting from atrophy of parts of the brain
Procrastination, noncompliance, and intentional inefficiency are characteristics of the client with:
- A. Avoidant personality disorder
- B. Antisocial personality disorder
- C. Compulsive personality disorder
- D. Passive aggressive personality disorder
Correct Answer: D
Rationale: Passive aggressive personality disorder is characterized by indirect resistance, such as procrastination and intentional inefficiency.
A male client's behavior begins to escalate into aggressive behavior.
The nurse is caring for clients on the psychiatric unit. Suddenly, a male client's behavior begins to escalate into aggressive behavior. It would be MOST important for the nurse to take which of the following actions?
- A. Utilize an organized team to place the client in seclusion.
- B. Leave the client alone in his room to identify feelings of anger.
- C. Redirect the client to a quiet activity to divert his attention and not disturb the other clients.
- D. Assist the client to identify and express his feelings of increasing anxiety, frustration, and anger.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) nurse can be helpful in using psychological/communication strategies before utilizing seclusion (2) leaving the client alone can become potentially dangerous to the client and the property (3) encouraging the client to become involved in a quiet activity might further escalate his frustration and anger because the ability to focus and concentrate is diminished due to an elevated anxiety level (4) correct-as client's anger begins to escalate, nurse can be helpful in using psychological/communication strategies before utilizing seclusion