A nurse is admitting a client to the medical-surgical unit. The Patient Self-Determination Act requires the nurse to perform which of the following actions during the admission process?

Provide the client with a list of eligible individuals who can serve as a health care proxy.

Document in the client's medical record if the client has advance directives.

Provide end-of-life education if the client has a terminal illness.

Ensure the client has an attorney to contact for assistance with end-of-life documents.

Answer and Explanation

The Correct Answer is B

A. Provide the client with a list of eligible individuals who can serve as a health care proxy. - While it is important for clients to have information about selecting a healthcare proxy, the Patient Self-Determination Act does not specifically require nurses to provide a list of eligible individuals. However, nurses should educate clients about their rights to designate a healthcare proxy if desired.
B. Document in the client's medical record if the client has advance directives. - This is the correct action required by the Patient Self-Determination Act. The act mandates that healthcare facilities receiving Medicare or Medicaid funds must inform clients about their rights to make decisions about their medical care, including the right to have advance directives. Nurses are responsible for documenting in the client's medical record whether the client has advance directives, such as a living will or durable power of attorney for healthcare.
C. Provide end-of-life education if the client has a terminal illness. - While providing end-of-life education is important for clients with terminal illnesses, it is not specifically mandated by the Patient Self-Determination Act. However, the act does require healthcare facilities to inform clients about their rights to make decisions about end-of-life care, including the right to have advance directives.
D. Ensure the client has an attorney to contact for assistance with end-of-life documents. - The Patient Self-Determination Act does not mandate that nurses ensure clients have an attorney for assistance with end-of-life documents. While legal assistance may be helpful for some clients in completing advance directives, it is not a requirement of the act.

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Correct Answer is B

Explanation

A. "Incident report completed. A copy will be placed in the client's medical record." This statement indicates the completion of the incident report but lacks essential information about what incident occurred. It does not provide details necessary for understanding the nature of the incident.
B. "Prescribed dressing change was accidentally omitted during the previous shift." This statement clearly identifies the nature of the incident, stating that a prescribed dressing change was missed. It provides factual information without assigning blame, which is appropriate for an incident report.
C. "A nurse accidentally omitted a prescribed dressing change. Will notify the provider tomorrow." While this statement acknowledges the omission, it lacks details about the incident and focuses on future actions rather than accurately documenting what occurred.
D. "Unable to complete a prescribed dressing change. However, dressing did not appear to be soiled." This statement does not accurately represent the situation. It implies that the dressing change was not completed due to the dressing not appearing soiled, which may not be the case. It does not acknowledge the omission of the prescribed dressing change.

A. "Did anything in particular make you feel this way?" B. "Do you ever think about harming yourself?" C. "How long have you had these feelings of uselessness?" D. "Would you tell me more about the changes you see in your body?"

Correct Answer is B

Explanation

A. "Did anything in particular make you feel this way?" - While exploring potential triggers for the client's feelings of uselessness is important, assessing for suicidal ideation takes precedence. However, this question can be asked after addressing the immediate safety concern.
B. "Do you ever think about harming yourself?" - This is the priority assessment question. Older adults experiencing feelings of uselessness and worthlessness may be at risk for suicidal ideation or self-harm. Asking about thoughts of self-harm allows the nurse to assess the client's safety and determine the need for immediate intervention.
C. "How long have you had these feelings of uselessness?" - While understanding the duration of the client's feelings is relevant, assessing for suicidal ideation is more critical in ensuring the client's safety.
D. "Would you tell me more about the changes you see in your body?" - Exploring the client's perception of physical changes is important for addressing body image concerns and promoting self-esteem. However, assessing for suicidal ideation takes precedence as it addresses the client's immediate safety.

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A nurse is admitting a client to the medical-surgical unit. The Patient Self-Determination Act requires the nurse to perform which of the following actions during the admission process?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is creating an incident report due to an accidental omission of a client's dressing change during the previous shift. Which of the following statements should the nurse document on the incident report form?

Correct Answer is B

Explanation

A nurse in a provider's office is talking with an older adult client who tells the nurse that they fear they are "aging badly" and feel "so useless." Which of the following assessment questions is the nurse's priority?

Correct Answer is B

Explanation

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