A nurse is admitting a client who is to undergo a surgical procedure. Under the Patient Self-Determination Act (PSDA), which of the following actions is the nurse's responsibility regarding the client's advance directives?
Assist the client in making decisions about the need for life support.
Notify the provider of the client's durable power of attorney for health care.
Clarify the legal competency of the client.
Ask the client whether they have created advance directives.
The Correct Answer is D
A. Assist the client in making decisions about the need for life support: Nurses can provide education about treatment options, but making decisions about life support is the client’s responsibility, often in consultation with their provider.
B. Notify the provider of the client's durable power of attorney for health care: While important in care planning, notifying the provider is not the nurse’s primary responsibility under the PSDA. The act requires that clients be asked about advance directives and informed of their rights first.
C. Clarify the legal competency of the client: Determining legal competency is a responsibility of the courts, not nurses. Nurses assess decision-making capacity, but under the PSDA, the main role is to ask and provide information about advance directives.
D. Ask the client whether they have created advance directives: The PSDA requires healthcare institutions to inform clients of their right to make decisions regarding their care, including the right to have advance directives. Asking about existing directives fulfills the nurse’s obligation under this law.
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Related Questions
Correct Answer is "{\"xRanges\":[33.882846916299556,42.693419603524234],\"yRanges\":[29.535864978902953,37.9746835443038]}"
Explanation
A. Throat/Pharynx area: The gag reflex must be checked before giving fluids. Anesthetics used during bronchoscopy suppress the gag and cough reflex, which places the client at high risk of aspiration. Assessing the throat for return of reflexes ensures safe swallowing.
B. Head/Brain area: Assessing the brain is not necessary prior to resuming oral intake after bronchoscopy. Neurological function is important overall, but it does not determine whether the swallowing reflex has returned and if the client can safely manage oral fluids.
C. Mouth/Lips: Examining the lips or oral cavity may reveal dryness, bleeding, or trauma, but it does not determine readiness for fluids. The risk of aspiration persists unless gag reflex recovery is confirmed.
D. Chest/Lungs area: Assessing lung sounds is important for evaluating complications such as bronchospasm or pneumothorax, but this does not confirm readiness for oral intake. Aspiration risk remains the main concern until gag reflex recovery is established.
Correct Answer is A
Explanation
A. Use a reflex hammer: Clonus is assessed by using a reflex hammer to test deep tendon reflexes, typically at the ankle joint. Sustained rhythmic contractions following dorsiflexion of the foot confirm the presence of clonus, which often indicates upper motor neuron dysfunction.
B. Administer magnesium sulfate: Magnesium sulfate is a treatment used in conditions such as preeclampsia with severe features but is not a method of assessment. Medication administration would come after clonus has been identified, not during the diagnostic step.
C. Perform a Romberg test: The Romberg test assesses balance and proprioception, often used in neurological exams for cerebellar or sensory dysfunction. It does not evaluate for clonus, which specifically relates to abnormal reflex activity.
D. Test the gait for symmetry: Gait assessment provides information about coordination, strength, and balance. While it may reveal neurologic impairment, it does not directly test for clonus or identify the rhythmic contractions associated with it.
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