A nurse is reinforcing teaching with a client about advance directives and a health care proxy.

Which of the following client statements indicates an understanding of the teaching?

Once my health care proxy is in place, I relinquish my right to make my own decisions.

If I have a health care proxy, then I do not need to have a living will.

My health care proxy designee is not able to sign a consent form on my behalf.

I do not need to name a relative as my designee in my health care proxy.

None

Answer and Explanation

The Correct Answer is D

A. Having a health care proxy does not mean that the individual relinquishes their right to make their own decisions. A health care proxy is designated to make decisions on behalf of the individual when they are unable to do so, but the individual retains the right to make decisions if they are capable.

B. Having a health care proxy does not eliminate the need for a living will. A living will outline the individual's specific wishes regarding medical treatments and end-of-life care, while a health care proxy designates a person to make decisions on their behalf. Both documents serve different purposes and can work together to ensure the individual's wishes are respected.

C. A health care proxy designee is typically empowered to make medical decisions on your behalf, including signing consent forms if necessary. This is one of the primary roles of a health care proxy – to act in your best interests when you are unable to make decisions yourself, including signing forms for procedures or treatments.

D. The individual has the choice to name any person as their health care proxy designee, regardless of their relationship. It is important to choose someone who understands the individual's wishes and can make decisions in their best interest. The decision of whom to name as the health care proxy designee is personal and should be based on trust and understanding.

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Correct Answer is C

Explanation

A.This is incorrect because suction should not be applied during the insertion of the catheter. Suctioning should only be applied while withdrawing the catheter to avoid causing trauma to the mucosa.

B. Suctioning should generally be performed for no longer than 10 seconds at a time to minimize the risk of complications such as hypoxia.

C.This response is correct because waiting approximately 1 minute between suctioning attempts allows the client time to recover and reoxygenate. This interval helps prevent hypoxia and mucosal damage, which are important considerations during the suctioning process.

D.In adults insert catheter approximately 16 cm (6.5 inches); in older children, 8– 12 cm (3–5 inches); in infants and young children, 4–7.5 cm (1.5–3 inches). Rule of thumb is to insert catheter distance from tip of nose (or mouth) to angle of mandible.

A. Release the client's restraints every 4 hr. B. Check the client's status every hour. C. Document the client's behavior leading to the initiation of the restraints. D. Obtain written consent by the client for the placement of the restraints.

Correct Answer is C

Explanation

Document the client's behavior leading to the initiation of the restraints: Accurate and comprehensive documentation is essential in the client's medical record. This includes documenting the client's behavior or actions that necessitated the use of restraints. It is important to document the reason, duration, and type of restraint used.

Release the client's restraints every 2 hours or as per institutional policy: It is important to periodically release the restraints to assess the client's circulation, skin integrity, and overall well-being. Restraints should never be kept on continuously without intermittent release. Check the client's status every 15 minutes: The nurse should closely monitor the client's vital signs, level of comfort, and any signs of distress or complications. Frequent assessment ensures early identification and intervention if any issues arise.

Obtain informed consent: While obtaining consent is necessary for many procedures or treatments, including the use of restraints, it is not applicable in situations where there is an imminent risk of harm to the client or others. The use of restraints in mental health units is based on legal and ethical guidelines, prioritizing the client's safety and the safety of others.

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A nurse is reinforcing teaching with a client about advance directives and a health care proxy. Which of the following client statements indicates an understanding of the teaching?

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A nurse is performing nasopharyngeal suctioning for an adult client. Which of the following techniques should the nurse use?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

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A nurse is reinforcing teaching with a client about advance directives and a health care proxy.

Which of the following client statements indicates an understanding of the teaching?