A nurse is documenting admission data for a client in an acute care facility. Which of the following actions should the nurse take?
Begin charting with an evaluation of the data.
Document the client’s vital signs obtained by an assistive personnel.
Chart a summary of the data at the change of shift.
Note whether the client has a living will.
The Correct Answer is D
Choice A reason: Beginning charting with an evaluation skips the initial step of collecting and documenting raw data, such as health history and vital signs, which is critical for accurate admission records. This approach risks incomplete documentation, potentially leading to misinformed care plans and overlooking advance directives like a living will, essential for patient-centered care.
Choice B reason: Documenting vital signs from assistive personnel is routine but not the priority during admission. Noting a living will is more critical to ensure legal and ethical care preferences are addressed. Relying solely on delegated data risks missing comprehensive admission details, potentially compromising care coordination and patient autonomy in acute settings.
Choice C reason: Charting a summary at shift change is not specific to admission documentation, which requires detailed initial data, including advance directives like a living will. Summarizing later risks delaying critical information, such as legal preferences, potentially leading to care decisions that conflict with the patient’s wishes in acute care scenarios.
Choice D reason: Noting whether the client has a living will is a priority during admission to ensure advance directives are documented, guiding ethical and legal care decisions. This ensures patient autonomy, especially in acute settings where critical decisions arise. Addressing this upfront prevents oversight, aligning care with the client’s wishes and regulatory standards.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Stating the client must accept treatment dismisses autonomy, escalating fear and mistrust in an involuntary admission. Exploring concerns is more therapeutic. This approach risks non-compliance, hindering recovery, critical to avoid in building trust and supporting mental health treatment in acute psychiatric settings.
Choice B reason: Asking why the client fears sleep-inducing medications explores concerns, fostering therapeutic communication and trust in involuntary admission. This validates feelings, reduces anxiety, and clarifies misconceptions, critical for promoting cooperation, ensuring effective treatment, and supporting recovery in clients with acute mental health needs.
Choice C reason: Promising to respect medication refusal is inaccurate in involuntary admissions, where court-ordered treatment may override refusal. Exploring fears is more appropriate. This risks misinformation, potentially escalating agitation, critical to avoid in ensuring accurate communication and compliance in acute mental health treatment settings.
Choice D reason: Emphasizing rest dismisses the client’s medication fears, reducing trust in involuntary admission. Exploring concerns is more therapeutic. Assuming rest is the focus risks alienating the client, hindering engagement, critical to avoid in fostering cooperation and effective mental health treatment in acute psychiatric care settings.
Correct Answer is B
Explanation
Choice A reason: Preeclampsia is not a contraindication for misoprostol; it may be used cautiously for labor induction in such cases under close monitoring. Transverse lie is a contraindication. Assuming preeclampsia contraindicates misoprostol risks unnecessary avoidance, potentially delaying necessary induction, critical for maternal and fetal safety in labor management.
Choice B reason: Transverse fetal lie is a contraindication for misoprostol, as it increases risks of uterine rupture or cord prolapse during labor induction due to improper fetal positioning. Cesarean delivery is preferred. Recognizing this prevents complications, ensuring maternal and fetal safety, critical in labor induction planning for malpresented fetuses.
Choice C reason: Intrauterine growth restriction is not an absolute contraindication for misoprostol; it may be used with caution if induction is indicated. Transverse lie is a clearer contraindication. Assuming restriction contraindicates risks delaying induction, potentially compromising fetal well-being, critical for timely labor management in growth-restricted pregnancies.
Choice D reason: Postterm pregnancy is an indication, not a contraindication, for misoprostol to induce labor and prevent fetal risks. Transverse lie is the contraindication. Assuming postterm contraindicates misoprostol risks delaying necessary induction, increasing risks like stillbirth, critical for ensuring safe delivery in prolonged pregnancies.
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