A client on the cardiac telemetry unit suddenly starts showing signs of ventricular fibrillation. The advanced cardiac life support (ACLS) team defibrillates the client, restoring a normal sinus rhythm. Later in the day, a family member Questions why the code was called, telling the nurse that the client has a living will.
How should the nurse respond?
Schedule a client and family conference to review the plan of care.
Explain that living wills cannot be followed by emergency personnel.
Check the client’s arm for a “Do Not Resuscitate” (DNR) bracelet.
Seek clarification of the type of advance directive the client has.
The Correct Answer is D
Choice D rationale
Seeking clarification of the type of advance directive the client has is the most appropriate response. A living will typically outlines a person’s wishes for end-of-life care, but it may not specifically address emergency situations like cardiac arrest.
Choice A rationale
Scheduling a client and family conference to review the plan of care may be helpful, but it is not the immediate priority. The nurse first needs to understand the client’s wishes as outlined in their advance directive.
Choice B rationale
Explaining that living wills cannot be followed by emergency personnel is not entirely accurate. While it’s true that emergency personnel initiating resuscitative measures may not have immediate access to a person’s living will, in a hospital setting, a person’s known wishes should be respected as much as possible.
Choice C rationale
Checking the client’s arm for a “Do Not Resuscitate” (DNR) bracelet is not the most appropriate response. While some people may choose to wear such a bracelet, not all do. Furthermore, a DNR order is just one type of advance directive, and it’s important to clarify what specific directives the client has in place.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Choice A rationale
Teaching the client how to use guided imagery can be a helpful intervention for coping with feelings related to death and dying. Guided imagery can help the client to relax, reduce stress and anxiety, and find comfort.
Choice B rationale
Instructing the client and family to reconsider end of life choices is not typically an appropriate intervention. The nurse should respect the client’s end of life choices and provide support, rather than suggesting they reconsider.
Choice C rationale
Recording the client’s desire to live is not typically an intervention used in hospice care. The focus in hospice care is on providing comfort and quality of life, rather than on prolonging life.
Choice D rationale
Encouraging the family to bring the client old photographs can be a helpful intervention. Looking at old photographs can stimulate memories and conversations, providing comfort and connection.
Choice E rationale
Encouraging the family to visit frequently can be a beneficial intervention. Frequent visits can provide the client with emotional support and companionship, which can be comforting when coping with feelings related to death and dying.
Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"C,B"},"C":{"answers":"B"}}
Explanation
Choice A rationale
Chronic alcoholism is often associated with both Vitamin B12 and Folic acid deficiency anemia. Alcohol interferes with the absorption of these vitamins in the gut, leading to their deficiency.
Choice B rationale
Malabsorption syndrome can lead to Iron deficiency anemia, Vitamin B12 deficiency anemia, and Folic acid deficiency anemia. In malabsorption syndrome, the small intestine can’t absorb enough of certain nutrients and fluids.
Choice C rationale
Dietary deficiency can result in Iron deficiency anemia, Vitamin B12 deficiency anemia, and Folic acid deficiency anemia. These types of anemia can occur when the body doesn’t have enough of the vitamins needed to produce enough healthy red blood cells.
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