A nurse is preparing to provide tracheostomy care for a client.

Which of the following actions should the nurse plan to take?

b, d, e, and f.

b. Initiate a power of atorney for health care document: One of the primary responsibilities of a nurse in relation to advance directives is to initiate the process of creating an advance directive. This includes assisting the client in completing a power of atorney for health care document, which designates a person to make healthcare decisions for the client if they are unable to do so.

d. Provide the client with writen information about advance directives: It is important for the nurse to provide the client with writen information about advance directives, including their rights and options for creating an advance directive. This information should be provided in a clear and understandable manner.

c. Communicate advance directives status via the medical record and shift report: The nurse should communicate the client's advance directives status to other members of the healthcare team via the medical record and shift report. This ensures that everyone involved in the client's care is aware of the client's wishes and can provide care that is consistent with those wishes.

f. Instruct the client that an advance directive is a legal document and must be honored by care providers: The nurse should instruct the client that an advance directive is a legal document that must be honored by care providers. This ensures that the client understands the importance of their advance directive and can advocate for their wishes if necessary.

a. Inform the client that an advance directive discontinues further care: This option is incorrect. An advance directive does not automatically discontinue further care. It simply provides guidance to healthcare providers on the client's wishes for medical treatment. It is important for the nurse to explain this to the client and ensure that they understand the purpose of an advance directive.

c. Document that the provider discussed do-not-resuscitate status with the client: This option is also incorrect. While discussing do-not-resuscitate status may be part of the advance directive process, it is not one of the primary responsibilities of the nurse in relation to advance directives. The nurse should ensure that the client's wishes regarding resuscitation are documented in their advance directive, but they do not need to document that the provider discussed this topic with the client.

Choice A Reason:

Posterior fontanel closed is incorrect, it is normal for the posterior fontanel to close earlier than the anterior fontanel, usually by 2 to 3 months of age.

Choice B Reason:

Anterior fontanel closed is correct. The anterior fontanel is the soft spot on the top of a baby's head, and it typically closes between 12 to 18 months of age. If the anterior fontanel is closed in a 4-month-old infant, it is considered an early closure, which can be a cause for concern. Early closure of the anterior fontanel can be associated with various underlying medical conditions, such as craniosynostosis (premature fusion of the skull bones) or dehydration.

Choice C Reason:

Plays with toes is incorrect. At 4 months of age, infants are typically developing their motor skills, and playing with their toes is a sign of normal development.

Choice D Reason:

Moves objects to mouth is incorrect. At this age, infants often explore their environment by bringing objects to their mouths as part of their sensory exploration and development.