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A nurse is reviewing information about advance directives
with a newly admitted client.
Which of the following statements by the client indicates an
understanding of the information?
c. Advance directives include a living well
A nurse on a medical surgical unit is assisting with the
admission of a client who has
advanced lung cancer. Which of the following actions regarding
advance directives should the
nurse take?
,b. Document the client's decision about end-of-life care in the
medical record
A nurse is reinforcing teaching with a client about advance
directives and a
healthcare proxy which of the following client statements and
the kids and
understanding of the teaching
➢ I do not need to name a relative as my designee in my health
care proxy
A nurse is reinforcing teaching about advance directives with
a client who has end-stage heart
failure. Which of the following statements by the client indicates
an understanding of the
teaching?
"I know I can change my advance directives if I need to in the
future."
A nurse is caring for a client who speaks a different language
than the nurse. Which of
the following actions should the nurse take?
Supplement spoken language with pictures. Or review the
,facility policy about the use of an
interpreter
A nurse is caring for a client who speaks a different language
than the nurse. The clients
partner tells the nurse that the client would like to go home
against medical advice (AMA). Which of the actions should the nurse
take?
a. Discharge the client and notify the health care provider
b. Request the services of an interpreter to determine the clients
wishes
c. Have the client's partner sign an AMA form
d. Ask the partner to reiterate the consequences of leaving AMA
to the client
b. Request the services of an interpreter to determine the clients
wishes
A nurse at long term care facility is reviewing the plan of care
who has a prescription for
mitten restraints. Which of the following tasks should the nurse
assign to assistive personnel?
a. Evaluate the need client
b. Assist the client with range of motion exercises of the hands
c. Determine the circulation status
, d. Instruct the client's family about purpose mitten restraint
b. Assist the client with range of motion exercises of the hands
8.A nurse in an acute mental health facility is caring for an
adolescent who is exhibiting
destructive behavior. Which of the following actions should the
nurse take after applying
physical restraints to the client?
a. Monitor the client's range of motion every 60 min.
b. Plan to remove the restraints as soon as the clients is calm
c. Offer the clients nutritious snack every 4 hr.
d. Ensure that the procedure has signed a prescription for
restrain within 48 hr.
b. Plan to remove the restraints as soon as the clients is calm
A nurse in a mental health facility receives a change of shift
report on 4 clients. Which of the
following clients should the nurse plan to assess first?
1. A client placed in restraints for aggressive behavior
2. A new limited client presents history of 4.5kg weight loss in
the past two
months
3. Client is receiving a PRN dose of haloperidol two hours ago