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 D

Explanation

A. Hemiparesis: Hemiparesis refers to weakness on one side of the body, which does not fully describe the inability to move only the legs.

B. Hypertonicity: Hypertonicity refers to increased muscle tone or stiffness, not the inability to move legs.

C. Crepitation: Crepitation refers to a crackling or popping sound in the joints, not the inability to move legs.

D. Paraplegia: Paraplegia refers to the paralysis of the lower half of the body, including the legs, which fits the description of the patient’s condition.

A. Scrub the stem of the ampule with antimicrobial wipe. B. Break the stem of the ampule away from the body C. Attach a filter needle to the syringe. D. Tap the stem of the ampule. E. Wrap the stem of the ampule with a sterile gauze pad.

Correct Answer is ["B","C","E"]

Explanation

A. Scrub the stem of the ampule with an antimicrobial wipe. This is not necessary because the stem of the ampule is broken and is not typically touched with hands or contaminated. The main concern is to prevent any glass from falling into the medication.

B. Break the stem of the ampule away from the body. Breaking the stem away from the body helps to prevent any shards of glass from falling into the medication or causing injury.

C. Attach a filter needle to the syringe. A filter needle is used to prevent any glass particles from entering the syringe when drawing up the medication from an ampule.

D. Tap the stem of the ampule. Tapping the stem may help remove any bubbles but is not a standard practice in ampule preparation.

E. Wrap the stem of the ampule with a sterile gauze pad. Wrapping the stem with a sterile gauze pad provides protection from glass shards and helps prevent injury when breaking the ampule.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a patient's musculoskeletal system after a swimming accident and notes that the patient can move both arms but is unable to move their legs. The nurse should document this finding as which of the following?

Correct Answer is D

Explanation

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Correct Answer is ["B","C","E"]

Explanation

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