A nurse is caring for a client with dementia who frequently tries to get out of bed. Which of the following actions should the nurse take?

Choice A rationale

Documenting emesis describes an observed occurrence but does not involve actively performing an intervention, thus representing assessment rather than implementation in client care.

Choice B rationale

Reporting pain as a numeric scale is part of assessment and data collection, not active implementation of nursing interventions aimed at client care.

Choice C rationale

Reporting the absence of nausea or vomiting indicates evaluation of an intervention's effectiveness, which occurs after implementation rather than during it.

Choice D rationale

Contacting the provider actively initiates communication and implementation of interventions, addressing client needs and collaborating with the healthcare team for enhanced care delivery.

Choice A rationale

While legal advice might assist, attorneys are not required to sign advance directives. Requirements vary by jurisdiction but typically involve witnesses or a notary for validity.

Choice B rationale

Living wills document clients’ preferences for medical care when decision-making is impaired. It is a central component of advance directives and demonstrates the client’s understanding.

Choice C rationale

Though appointing a health care proxy is an option, it is not mandatory for advance directives. Living wills alone can suffice to outline preferences without assigning a proxy.

Choice D rationale

Advance directives generally address situations where resuscitation is undesired, such as DNR orders, rather than requiring explicit documentation for resuscitation preferences, making this statement inaccurate.

NGN QUESTIONS