A nurse is teaching a client about advance directives. Which of the following statements by the client indicates an understanding of the teaching?
"I will have a nurse witness the signing of my living will."
"I can make changes to my living will even after I sign it."
"I should choose a family member as my health care proxy."
"I need to have my attorney review my advance directives."
The Correct Answer is B
Choice A Reason:
"I will have a nurse witness the signing of my living will." This statement is incorrect. While having a witness present during the signing of a living will is important for validity in some jurisdictions, the statement alone does not demonstrate an understanding of advance directives. It's essential to ensure that the client comprehends the purpose and content of the document, not just the procedural aspect.
Choice B Reason:
"I can make changes to my living will even after I sign it." This statement is correct. Understanding that living wills can be revised or updated as needed reflects comprehension of the flexibility and control that advance directives provide. It's crucial for clients to know that they can make changes to their directives if their preferences or circumstances change.
Choice C Reason:
"I should choose a family member as my health care proxy." This statement is incorrect. While selecting a family member as a health care proxy is a common choice, it may not necessarily indicate an understanding of advance directives. The key aspect is that the client understands the role of the health care proxy and chooses someone who can make decisions aligned with their wishes.
Choice D Reason:
"I need to have my attorney review my advance directives." This statement is incorrect. While it can be beneficial to have an attorney review advance directives for legal clarity and compliance with state laws, it is not a requirement for their validity. The statement alone does not demonstrate understanding of advance directives.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Listing names of witnesses to the fall in the nurses' notes is incorrect. While it's important to document witnesses to the fall, listing their names in the nurses' notes is not the primary action related to incident reporting. Witness information is typically included in the incident report itself.
Choice B Reason:
Sending the incident report to the ethics committee is incorrect. Incident reports are typically submitted to the appropriate department within the healthcare facility responsible for managing incidents and ensuring appropriate follow-up. Sending the incident report to the ethics committee may not be necessary unless there are specific ethical concerns related to the incident.
Choice C Reason:
Includes the client's account of the fall in the incident report is correct. When a client falls, it's essential to document the incident accurately and thoroughly. Including the client's account of the fall in the incident report demonstrates an understanding of the procedure because it provides valuable information about the circumstances surrounding the fall from the client's perspective.
Choice D Reason:
Documenting in the client's record that an incident report was filed is incorrect. Documenting in the client's record that an incident report was filed is a necessary step, but it doesn't provide detailed information about the incident itself. The incident report itself should contain comprehensive details about the fall, including the client's account, witnesses, actions taken, and any resulting injuries.
Correct Answer is C
Explanation
Choice A Reason:
Telling the client that their blood alcohol level will be checked is incorrect. Threatening the client with other forms of testing may not be ethically or legally appropriate, especially if the client has refused the initial request. It's important to respect the client's autonomy and right to refuse testing.
Choice B Reason:
Informing the client that a catheter will be inserted is incorrect. Inserting a catheter against the client's will is invasive and would constitute a violation of the client's autonomy and bodily integrity. It is not an appropriate action.
Choice C Reason:
Documenting the client's refusal in their chart is correct. Documenting the client's refusal is essential for accurate record-keeping and ensures that the healthcare team is aware of the client's decision. It also helps protect the nurse and the healthcare facility in case of any legal or ethical challenges related to the client's refusal.
Choice D Reason:
Assessing the client for urinary retention is incorrect. While urinary retention may be a concern in some cases, it is not the immediate action to take when a client refuses to provide a urine sample. The priority is to respect the client's autonomy and document their refusal appropriately. If there are clinical indications or concerns about urinary retention, they can be assessed separately and addressed accordingly.
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