A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, and time, and has advance directives. The client is scheduled for a procedure that requires informed consent. Which of the following persons should sign the informed consent?

The client's daughter, who is the primary caregiver

The client

The client's partner

The client's son, who has a durable power of attorney

Answer and Explanation

The Correct Answer is B

A. The client's daughter, who is the primary caregiver: While the daughter may be involved in the client's care and decision-making process, the client themselves should provide informed consent if they have decision-making capacity. Informed consent cannot be provided by a caregiver unless legally authorized to do so.

B. The client: The client is alert, oriented, and has advance directives. In this scenario, the client possesses decision-making capacity and is capable of providing informed consent for the procedure. As long as the client is competent and able to understand the nature, risks, benefits, and alternatives of the procedure, they are the appropriate person to sign the informed consent document.

C. The client's partner: Unless legally designated as the client's healthcare proxy or legally authorized to provide consent on the client's behalf, the partner should not sign the informed consent document. The client themselves should provide consent if they have decision-making capacity.

D. The client's son, who has a durable power of attorney: While a durable power of attorney grants legal authority to make healthcare decisions on behalf of the client if they lack decision-making capacity, it does not negate the client's ability to provide informed consent if they are competent to do so. If the client is alert, oriented, and capable of understanding the procedure, they should sign the informed consent document themselves.

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Correct Answer is D

Explanation

A) Irritable: Irritability is more closely associated with emotional responses to stress rather than cognitive responses. While irritability can be a manifestation of stress, it primarily reflects emotional tension rather than cognitive impairment.

B) Lethargic: Lethargy is a physical response to stress rather than a cognitive one. It refers to a lack of energy, motivation, or enthusiasm, which can result from stress-induced fatigue or exhaustion.

C) Angry: Anger is also primarily an emotional response to stress rather than a cognitive one. While stress can contribute to feelings of anger or frustration, it does not directly reflect cognitive impairment or alterations in cognitive functioning.

D) Decreased attention to detail: Cognitive responses to stress can include difficulty concentrating, decreased attention to detail, memory problems, and impaired decision-making. When a client demonstrates decreased attention to detail, it indicates cognitive impairment or distraction, which can be a response to stress. This behavior suggests that the client's cognitive functioning is affected by the stress they are experiencing.

A. Allow the client to rest for 10 to 15 seconds after each suctioning attempt. B. Set the suction pressure to 110 mm Hg C. Apply suction for less than 10 seconds. D. Apply suction when inserting the catheter.

Correct Answer is ["A","C"]

Explanation

A) Allow the client to rest for 10 to 15 seconds after each suctioning attempt: Allowing the client to rest between suctioning attempts helps to minimize hypoxemia and reduces the risk of trauma to the airway mucosa. It also allows the client to recover from the physiological stress of suctioning before initiating another attempt.

C) Apply suction for less than 10 seconds: Prolonged suctioning can lead to hypoxemia and tissue trauma. The nurse should limit suctioning to less than 10 seconds per pass to minimize these risks and prevent complications such as mucosal damage and bleeding.

B) Set the suction pressure to 110 mm Hg: The appropriate suction pressure for endotracheal suctioning depends on various factors, including the client's age, condition, and clinical status. While suction pressures of 80 to 120 mm Hg are commonly used for adults, the specific pressure setting should be individualized based on the client's needs and should not exceed the safe range to prevent mucosal injury or hypoxemia.

D) Apply suction when inserting the catheter: Suction should be applied only during withdrawal of the catheter to minimize the risk of mucosal trauma and hypoxemia. Applying suction during catheter insertion can increase the risk of airway trauma and should be avoided.

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A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, and time, and has advance directives. The client is scheduled for a procedure that requires informed consent. Which of the following persons should sign the informed consent?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After an assessment, the nurse realizes that a client demonstrates cognitive responses to stress. What behaviors did the client demonstrate for the nurse to make this clinical determination?

Correct Answer is D

Explanation

A home health nurse is teaching about endotracheal suctioning. Which of the following information should the nurse include in the teaching?

Correct Answer is ["A","C"]

Explanation

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