The nurses talking with the spouse of an older adult client who has been diagnosed with dementia. The spouse states, "What will I do when my spouse cannot make decisions anymore?" Which of the following responses should the nurse make?

You have plenty of time to figure all of that out."

"Decisions will then be made for your spouse by the health care provider."

"Decisions should be made now for your spouse's future."

I can explain advance care planning to you."

Answer and Explanation

The Correct Answer is D

A. "You have plenty of time to figure all of that out." This response is not proactive and may not address the urgency of planning for future decisions. It is important to address these issues sooner rather than later.

B. "Decisions will then be made for your spouse by the health care provider." Healthcare providers will make decisions based on medical criteria and the patient's current condition, but they will typically follow the wishes expressed in advance directives or legal documents.

C. "Decisions should be made now for your spouse's future." This is a proactive approach, but it's important to involve the spouse in the decision-making process.

D. "I can explain advance care planning to you." This is the most appropriate response. Advance care planning involves discussing the client's wishes regarding their future care, including decisions about life-sustaining treatments. By explaining this process, the nurse can help the spouse prepare for a time when the client may be unable to make their own decisions.

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Correct Answer is A

Explanation

A. "Can you describe the feeling you are experiencing?" Asking the patient to describe their sensation helps identify the nature of their discomfort and guides appropriate pain management or further investigation.

B. "Would you like me to give you some pain medication?" Offering pain medication may address the discomfort, but it is important to first understand the nature and severity of the pain.

C. "Do you feel better sitting in the chair?" This question assesses the patient’s comfort but does not address the cause of the pain or discomfort.

D. "Let me know if you are still uncomfortable in the chair." This is a follow-up question rather than an initial assessment, and it may not be proactive enough in addressing the cause of pain.

A. Verify the client's code status. B. Begin cardiopulmonary resuscitation. C. Provide comfort measures until family arrives. D. Initiate a slow code response.

Correct Answer is B

Explanation

A. Verify the client's code status: Although verifying code status is important, it may delay necessary emergency interventions. In an urgent situation where the code status is unknown, immediate action is required.

B. Begin cardiopulmonary resuscitation (CPR). When a client is pulseless and the code status is unknown, the priority is to start CPR while emergency services are called. This ensures that the client receives potentially life-saving care promptly.

C. Provide comfort measures until family arrives. This is not appropriate if the client is pulseless and immediate resuscitation efforts are needed.

D. Initiate a slow code response. A slow code is not appropriate in an emergency situation where the patient requires immediate resuscitation.

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The nurses talking with the spouse of an older adult client who has been diagnosed with dementia. The spouse states, "What will I do when my spouse cannot make decisions anymore?" Which of the following responses should the nurse make?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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