A home health nurse is caring for a client who has terminal cancer and no longer wants to receive enteral tube feedings. Which of the following actions should the nurse take?
Request the facility chaplain to visit the client.
Ask the client to sign an informed consent form.
Explain the process for completing a living will.
Complete an against medical advice form.
The Correct Answer is C
When caring for a client with terminal cancer who expresses a desire to discontinue enteral tube feedings, the nurse's priority is to ensure that the client's wishes are respected and appropriate steps are taken. The most suitable action is:
c) Explain the process for completing a living will.
A living will is a legal document that outlines a person's preferences regarding medical treatment in the event they are unable to communicate their wishes. In this situation, the client can express their desire to forgo enteral tube feedings through a living will, ensuring that their wishes are documented and legally recognized.
The other options may not be as appropriate:
a) Request the facility chaplain to visit the client: While spiritual and emotional support is important, the immediate concern is ensuring the client's autonomy in decision-making regarding medical interventions.
b) Ask the client to sign an informed consent form: Informed consent typically pertains to specific medical procedures, and discontinuing enteral tube feedings is more aligned with the broader context of advance care planning.
d) Complete an against medical advice form: This form is typically used when a patient refuses a recommended treatment against the medical team's advice. However, in this case, the client is expressing their own treatment preferences, and the focus should be on facilitating advance care planning and documentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Explanation: Heroin is a central nervous system depressant that can cause various physiological effects on the body. Dilated pupils are a common sign of heroin use, along with a decrease in blood pressure, respiratory rate, and heart rate. The pupils will appear larger than usual because heroin depresses the parasympathetic nervous system, which controls the size of the pupils.
Tachypnea, or rapid breathing, is not typically associated with heroin use, as it is a central nervous system depressant. Euphoria, or a feeling of intense pleasure or happiness, is a common effect of heroin use, but it is not the most reliable sign of heroin use, as other drugs can also produce this effect. Nystagmus, an involuntary movement of the eyes, is not a common sign of heroin use. Dilated pupils are a reliable sign of heroin use and should be documented in the client's medical record. It is important for the nurse to assess for other signs of drug use and to provide appropriate care and support to the client, which may include referrals for substance abuse treatment. The nurse should also follow agency policies and procedures for reporting drug use and abuse to appropriate authorities.
Correct Answer is D
Explanation
Children with leukemia are at risk for developing oral mucositis, which is inflammation and ulceration of the oral mucosa due to the destruction of rapidly dividing cells by chemotherapy. Inspecting the child's mouth for sores and providing appropriate mouth care is essential to prevent infection and to maintain hydration and nutrition. Riding a bicycle is not recommended for a child with leukemia because of the risk of falls and injuries, and the measles, mumps, and rubella vaccine is contraindicated for children with leukemia who are receiving chemotherapy. Measuring the temperature orally or axillary is a safe and accurate method for monitoring the child's temperature.
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