A nurse is reinforcing education about advance directives to a client who has end-stage liver failure. Which of the following statements by the client reflects an understanding of advance directives?
"My family has the right to override my health care decisions if I have advance directives in place."
"The two types of advance directives documents are a living will and a power of attorney for finances."
"My advance directives will be kept at my lawyer's office in the event they are needed."
"I can make my health care wishes known through advance directives."
The Correct Answer is D
A. Family members cannot override a client’s advance directives; the client’s wishes must be followed as stated in the legal document.
B. A power of attorney for finances is not part of advance directives. The correct term is durable power of attorney for health care, which designates someone to make medical decisions if the client becomes unable.
C. Keeping advance directives only at a lawyer’s office may delay access during a medical emergency; copies should be readily available to health care providers and family.
D. Advance directives allow clients to express their health care wishes in advance, ensuring their treatment preferences are respected if they cannot communicate later.
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Related Questions
Correct Answer is C
Explanation
A. This indicates decreased urine output (oliguria), which could suggest impaired renal perfusion or fluid imbalance. Although concerning, it does not take immediate priority over airway compromise.
B. This change is important to monitor but does not pose an immediate threat to airway, breathing, or circulation. The nurse can assess this client after stabilizing those with life-threatening conditions.
C. According to the ABCDE (Airway, Breathing, Circulation, Disability, Exposure) priority framework, this client should be seen first because wheezing indicates airway narrowing or obstruction and impaired gas exchange. This poses an immediate threat to breathing, requiring prompt assessment and intervention (e.g., bronchodilators, oxygen therapy).
D. While the fever requires follow-up and may delay discharge, it is not an immediate life-threatening concern compared to airway compromise from wheezing.
Correct Answer is B
Explanation
A. Health education involves providing information or teaching clients how to make informed health decisions. While education may occur during screening, the primary focus in this scenario is preventing disease through early detection.
B. Performing a blood pressure screening is a form of secondary prevention, aimed at early detection and intervention to prevent the progression of hypertension. The nurse is helping identify risk or early signs of disease before complications develop.
C. Holistic health focuses on caring for the whole person—including physical, emotional, social, and spiritual aspects. This scenario emphasizes medical screening, not holistic care.
D. Health promotion focuses on encouraging behaviors that enhance overall well-being (e.g., exercise, balanced diet). In contrast, a screening specifically targets disease prevention through early identification of risk factors.
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