A nurse is evaluating a newly licensed nurse's understanding of advance directives. The newly licensed nurse should identify that which of the following individuals is responsible for deciding whether a client is capable of making their own decisions regarding medical treatment?

Primary provider

Charge nurse

Health care surrogate

Social worker

Answer and Explanation

The Correct Answer is A

A. Primary provider: The primary provider is responsible for assessing a client’s capacity to make their own medical decisions. They determine whether the client is able to understand the nature of their condition and the treatment options available.

B. Charge nurse: While the charge nurse plays an important role in overseeing nursing care and ensuring proper communication, the decision about whether a client is capable of making their own medical decisions falls to the primary provider, not the charge nurse.

C. Health care surrogate: A health care surrogate is an individual designated to make medical decisions for a client when they are unable to do so themselves. However, the primary provider is responsible for determining if the client has the capacity to make decisions before a surrogate is involved.

D. Social worker: Social workers provide support and assistance with advance directives and decision-making, but the responsibility for evaluating whether the client can make medical decisions lies with the primary provider, not the social worker.

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Correct Answer is C

Explanation

A. Bathe the client with soap and hot water: Hot water and soap can dry out the skin and worsen skin breakdown. The nurse should use lukewarm water and mild soap to prevent skin irritation, ensuring proper hydration and skin care.

B. Massage bony prominences four times daily: Massaging bony prominences can increase the risk of skin breakdown, as it may cause further tissue damage. Instead, the nurse should avoid massaging these areas and focus on preventive measures, such as repositioning.

C. Keep the head of the client's bed at 30° or less: Keeping the head of the bed at a 30° angle or less reduces pressure on the sacrum and other bony prominences. This position helps prevent further skin breakdown and promotes comfort for immobile clients.

D. Slide the client up in bed every 2 hr: Sliding the client up in bed increases friction, which can exacerbate skin breakdown. The nurse should use proper lifting techniques or assistive devices to reposition the client while minimizing friction and shearing forces.

A. Keep eyes open during relaxation therapy. B. Tighten and relax muscles during relaxation therapy. C. Plan to meditate immediately after meals. D. Take short and shallow breaths when meditating

Correct Answer is B

Explanation

A. Keep eyes open during relaxation therapy: Keeping the eyes closed is typically recommended during relaxation and meditation to help focus and avoid external distractions. Keeping the eyes open can interfere with the ability to achieve a relaxed state.

B. Tighten and relax muscles during relaxation therapy: Progressive muscle relaxation involves tightening and then relaxing each muscle group to help reduce tension and promote relaxation. This technique helps increase body awareness and alleviate stress.

C. Plan to meditate immediately after meals: Meditating immediately after meals can be uncomfortable because it may cause indigestion or distract from the relaxation process. It’s better to meditate when the stomach is not full to avoid discomfort.

D. Take short and shallow breaths when meditating: Deep and slow breathing is a key component of meditation and relaxation techniques. Short and shallow breaths can increase stress rather than reduce it, as they may activate the body's "fight or flight" response. Deep breathing helps activate the parasympathetic nervous system, which promotes relaxation.

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A nurse is evaluating a newly licensed nurse's understanding of advance directives. The newly licensed nurse should identify that which of the following individuals is responsible for deciding whether a client is capable of making their own decisions regarding medical treatment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is immobile and developing skin breakdown. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is teaching a client about meditation and progressive relaxation to reduce stress. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

A nurse is planning teaching for a client who will be discharged with a central venous access device. Which of the following actions should the nurse plan to take first?

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