A nurse is caring for a client who is unresponsive and has advance directives stating they do not want treatment to extend their life. The client's partner is their health care surrogate and requests the nurse begin tube feedings. Which of the following responses should the nurse make?

"The ethics committee will need to make that decision."

"The client's wishes are to not be given life-saving treatment."

"Your partner will feel better with tube feeding."

"We should discuss this with the rest of your partner's family."

Answer and Explanation

The Correct Answer is B

A. Involving the ethics committee may be unnecessary if the client's advance directives are clear.

B. This response directly addresses the client's wishes as stated in their advance directives, reinforcing the importance of honoring their preferences regarding life-sustaining treatment.

C. Suggesting that tube feeding will make the client feel better contradicts the advance directives and does not respect the client's wishes.

D. Discussing the matter with the rest of the family may not be appropriate if the partner is the designated surrogate and the client's wishes are clearly outlined in the advance directives.

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Correct Answer is B

Explanation

A. While repositioning is important to prevent pressure ulcers and promote circulation, it is not the priority intervention in this context.

B. Using an incentive spirometer is crucial for preventing atelectasis and promoting lung expansion following surgery, making it a priority intervention.

C. Ensuring adequate fluid intake is important for hydration and recovery but does not take precedence over respiratory care in the postoperative setting.

D. Increasing the amount of time spent out of bed is beneficial for recovery but should follow ensuring proper respiratory function and lung expansion, which is addressed by the use of the incentive spirometer.

A. A client who has schizophrenia and uses neologisms B. A client who has bipolar disorder and displays constant pacing C. A client who has depressive disorder and has poor personal hygiene D. A client who has dementia and exhibits aphasia

Correct Answer is B

Explanation

A. A client with schizophrenia using neologisms may have communication challenges, but this does not indicate immediate risk.

B. A client with bipolar disorder who displays constant pacing may be in a manic state, which can lead to agitation or unsafe behaviors, making this client the highest priority for assessment and intervention.

C. A client with depressive disorder and poor personal hygiene requires support but does not present an immediate risk to themselves or others.

D. A client with dementia exhibiting aphasia requires assistance with communication but is not in a critical situation that requires urgent intervention.

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A nurse is caring for a client who is unresponsive and has advance directives stating they do not want treatment to extend their life. The client's partner is their health care surrogate and requests the nurse begin tube feedings. Which of the following responses should the nurse make?

Nursing Test Bank

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