The nurse is working in a clinic and sees a resident of a long-term-care facility, age 82 years, who has come in to be checked by her physician.
The caregiver accompanying her reports that the client has been displaying the following: drowsiness, excessive sleeping, decreased attention span, irritability, and signs of depression.
The client's daughter and family, who usually visit her, moved away from the area 6 weeks ago due to the husband's job.
The nurse suspects which problem?

Choice A rationale

Emptying a Foley catheter bag and reporting the urine volume is a routine task that does not require complex assessment or clinical judgment. Unlicensed care providers are typically trained in this procedure and can accurately measure and report the output to the nurse.

Choice B rationale

Helping a first-time mother achieve a good latch during breastfeeding requires specialized knowledge and assessment skills to ensure proper positioning and infant feeding. This task involves teaching and evaluating, which falls within the scope of nursing practice and should not be delegated to an unlicensed care provider.

Choice C rationale

Assessing the size and quantity of blood clots in a postpartum client's bedpan requires clinical judgment to determine if the findings are within normal limits or indicative of a potential complication. This assessment should be performed by a registered nurse who can interpret the findings in the context of the client's overall condition.

Choice D rationale

Administering medication, including anti-inflammatory drugs, is a nursing responsibility that requires knowledge of pharmacology, potential side effects, and client assessment. Medication administration should not be delegated to unlicensed care providers. .

Choice A rationale

While it might seem natural to inquire about prior discussions, this response could induce guilt or regret in the spouse and doesn't directly address the current emotional distress and uncertainty about the spouse's wishes as explicitly stated in the advance directive. It shifts the focus to the past rather than the present need for clarification regarding the existing directive.

Choice B rationale

Although the primary care provider may indeed have the client's best interests in mind, this statement dismisses the spouse's expressed uncertainty and relies on an assumption about the PCP's motivations. It doesn't help the spouse understand or feel confident about the content of the advance directive, which is the core of their concern.

Choice C rationale

This statement, while true, places the burden of decision-making solely on the spouse without acknowledging the existence of the advance directive, which is meant to guide such decisions. It overlooks the possibility that the directive already contains the spouse's wishes and could offer clarity, thereby increasing the spouse's anxiety.

Choice D rationale

This response directly addresses the spouse's statement by reminding them that their spouse's wishes are likely documented in the advance directive. It encourages the spouse to review the directive, which is the most direct way to understand what their spouse wanted regarding medical interventions like a PEG tube, thus providing immediate and relevant support.