A nurse is caring for a client who asks for information about advance directives and states, “I want to make sure my wishes are respected.” Which of the following responses should the nurse make?

I cannot be a witness to your advance directives in writing.

Your desire to have advance directives can be included in your medical record.

Your name can be removed from your advance directives at any time.

You must be at least 21 years old to complete advance directives.

Answer and Explanation

The Correct Answer is B

Choice A reason: Nurses can witness advance directives in many settings, depending on state laws, so stating they cannot is inaccurate. This response dismisses the client’s request without providing guidance, making it incorrect and unhelpful for addressing their wishes.
Choice B reason: Including the client’s desire for advance directives in the medical record ensures their wishes are documented and respected. This aligns with the Patient Self-Determination Act, facilitating care planning, making it the correct and supportive response.
Choice C reason: Stating the client’s name can be removed from advance directives is confusing, as directives are personal and revocable, not about name removal. This response is inaccurate and irrelevant to the client’s request, making it incorrect.
Choice D reason: There is no universal age requirement of 21 for advance directives; competent adults (typically 18+) can create them. This statement is incorrect and restrictive, misinforming the client about their rights, making it inappropriate.

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Correct Answer is C

Explanation

Choice A reason: Encouraging ambulation only after 48 hours delays recovery, as early ambulation (within 12-24 hours) promotes circulation, prevents thromboembolism, and aids bowel function post-abdominal surgery. This instruction is incorrect, as it contradicts evidence-based protocols for early mobilization to enhance recovery.
Choice B reason: Instructing clients to avoid coughing is inappropriate, as coughing and deep breathing prevent pulmonary complications like atelectasis post-abdominal surgery. Splinting the incision during coughing reduces discomfort and dehiscence risk, making this instruction incorrect as it increases respiratory complications.
Choice C reason: Monitoring for signs of infection, such as fever or redness, is critical post-abdominal surgery to detect complications early. Infections can delay healing and lead to sepsis. Regular assessment ensures timely intervention, aligning with evidence-based postoperative care, making this the correct information to include.
Choice D reason: Removing surgical dressings within 12 hours is not standard, as dressings typically remain for 24-48 hours or per surgeon orders to protect the wound and reduce infection risk. Premature removal increases contamination risk, making this instruction incorrect for postoperative care.

A. The client exhibits increased energy and motivation. B. The client experiences self-doubt when making decisions. C. The client reports sleeping 12 hours per day. D. The client isolates themselves from social interactions.

Correct Answer is A

Explanation

Choice A reason: Increased energy and motivation signal improvement in major depressive disorder, countering fatigue and anhedonia. Serotonin and norepinephrine rebalance, often from treatment, restores drive and engagement, reflecting neurochemical stabilization in the brain’s limbic system, critical for mood regulation and recovery.
Choice B reason: Self-doubt in decision-making reflects persistent depressive symptoms, like low self-esteem and cognitive impairment. Negative thought patterns, driven by altered prefrontal cortex activity, indicate ongoing depression, not improvement, requiring adjusted interventions to address these neurocognitive deficits in major depressive disorder.
Choice C reason: Sleeping 12 hours daily indicates hypersomnia, a depressive symptom, suggesting no improvement. Disrupted circadian rhythms and serotonin dysregulation cause excessive sleep, contrasting with recovery signs like normalized sleep patterns. This reflects persistent neurochemical imbalances hindering mood stabilization in depression.
Choice D reason: Social isolation is a core depressive symptom, driven by anhedonia and low mood, indicating no improvement. Withdrawal reflects ongoing dopamine and serotonin imbalances, preventing social engagement. Recovery involves increased interaction, making isolation a sign of persistent major depressive disorder.

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A nurse is caring for a client who asks for information about advance directives and states, “I want to make sure my wishes are respected.” Which of the following responses should the nurse make?

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