A nurse is caring for an older adult client who reports difficulty making health-related decisions. The client asks if it is possible to have a trusted friend make these decisions. Which of the following actions should the nurse take first?
Call the provider to discuss the client's preference with them and their family.
Explain to the client the process of designating another individual to make decisions for them.
Ask the client to discuss these preferences with their family first.
Ask the client if they would like their wishes documented in their health care records.
The Correct Answer is B
A. Call the provider to discuss the client's preference with them and their family: While involving the provider and family is important, the first step should be to educate the client about their options for designating a decision-maker.
B. Explain to the client the process of designating another individual to make decisions for them: The nurse should first provide information about how the client can designate a trusted individual to make decisions for them, such as through a durable power of attorney for healthcare. This allows the client to make an informed decision.
C. Ask the client to discuss these preferences with their family first: The nurse should first empower the client by explaining the process of designating a decision-maker. It is crucial to respect the client’s autonomy in making this decision before involving family.
D. Ask the client if they would like their wishes documented in their health care records: Before documenting, the nurse should ensure the client understands the process of assigning a decision-maker. Documentation is important, but the client needs to understand their options first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Discuss the client's condition with a nurse on another unit: Sharing a client’s condition with a nurse on another unit without a need-to-know basis violates confidentiality rules. Discussions about client conditions should be limited to personnel involved in care.
B. Fax client information with a cover sheet: A fax cover sheet protects the confidentiality of client information by identifying the contents and indicating that it is confidential. This ensures that the information is not exposed to unauthorized individuals during transmission.
C. List the client's name and condition on board at the nurses station: Displaying client information in public or semi-public areas, violates confidentiality. Client information should be kept private and only accessed by those who are involved in the client’s care.
D. Post client diagnosis on message board in their room: Posting the client’s diagnosis in their room is a violation of confidentiality, as other individuals (like visitors or hospital staff) may have access to that information without a need to know.
Correct Answer is D
Explanation
A. Prop the feet up: Proping the feet up may not be effective in preventing plantar flexion contractures, as it does not provide sustained support to keep the feet in a neutral position. Plantar flexion can still occur with this position.
B. Apply an abduction pillow to the legs: An abduction pillow is used to keep the hips in a neutral position, not to prevent plantar flexion contractures. It is useful for preventing hip contractures but not specifically for the feet.
C. Use a trochanter roll: A trochanter roll helps prevent external rotation of the hip joint, not plantar flexion of the feet. It is used for positioning to prevent hip complications, but it does not address foot position or contracture prevention.
D. Use foot splints: Foot splints are designed to keep the feet in a neutral or dorsiflexed position, preventing the toes from pointing downward (plantar flexion). This is the most effective intervention to prevent plantar flexion contractures in an immobile client.
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