The practical nurse (PN) should collect the following information during the admission assessment of a terminally ill client to an acute care facility:
Health care proxy documentation
Name of funeral home to contact
Client's wishes regarding organ donation
Contact information for the client's next of kin
The Correct Answer is A
The correct answer and explanation is:
a) Health care proxy documentation.
This is the information that the PN should collect during the admission assessment of a terminally ill client to an acute care facility. Health care proxy documentation is a legal document that appoints a person to make health care decisions for the client when they are unable to do so themselves. It is important to have this information in case the client's condition deteriorates and they need end-of-life care.
b) Name of funeral home to contact.
This is not the information that the PN should collect during the admission assessment of a terminally ill client to an acute care facility. Name of funeral home to contact is a personal preference that may or may not be relevant for the client at this point. It is not a priority for the admission assessment, and it may be insensitive or inappropriate to ask the client about it.
c) Client's wishes regarding organ donation.
This is not the information that the PN should collect during the admission assessment of a terminally ill client to an acute care facility. Client's wishes regarding organ donation are a personal choice that may or may not be applicable for the client depending on their diagnosis, prognosis, and eligibility. It is not a priority for the admission assessment, and it may be offensive or upsetting to ask the client about it.
d) Contact information for the client's next of kin.
This is not the information that the PN should collect during the admission assessment of a terminally ill client to an acute care facility. Contact information for the client's next of kin is a general demographic data that may or may not be relevant for the client's care. It is not a priority for the admission assessment, and it may be already available in the client's records.
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Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Encouraging the client to exercise every day to eliminate bedtime wakefulness is not appropriate advice in this scenario. It oversimplifies the issue and may not address the underlying causes of the client's sleep difficulties. Additionally, excessive exercise close to bedtime may actually interfere with sleep.
Choice C rationale:
Asking the client for a description of the exercise schedule being followed is a reasonable action. It allows the nurse to gather information about the client's exercise routine and assess whether it might be contributing to the sleep difficulties. However, this alone may not fully address the client's concerns.
Choice D rationale:
Determining the amount of weight the client has lost since increasing activity is relevant to the client's overall health and progress toward weight loss goals, but it does not directly address the issue of sleep difficulties. Weight loss and improved sleep may not always have a direct cause-and-effect relationship.
Correct Answer is A
Explanation
The correct answer is **a. Report the finding to the healthcare provider.**
Choice A rationale:
The nurse should report the finding of the client's response to a painful stimulus to the healthcare provider. This response, known as a decorticate posturing, is an abnormal motor response that indicates a severe brain injury or dysfunction. It is a sign of impaired consciousness and requires immediate medical attention and intervention.
Choice B rationale:
While documenting the client's response to pain is important, the primary action the nurse should take is to report the finding to the healthcare provider. Decorticate posturing is a neurological emergency that requires prompt medical evaluation and treatment.
Choice C rationale:
Initiating seizure precautions is not the appropriate action in this case. Decorticate posturing is not a seizure, but rather an abnormal motor response indicating a severe brain injury or dysfunction. Seizure precautions would not be the appropriate intervention.
Choice D rationale:
Administering a prescribed PRN analgesic is not the appropriate action in this case. Decorticate posturing is a neurological emergency that requires immediate medical attention, not just pain management. Administering an analgesic would not address the underlying neurological issue.
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