The nurse is discussing advance directives with a client. Which statement by the client indicates good understanding of the purpose of an advance directive?
a. "An advance directive will keep my children from selling my home when I'm old."
b. "An advance directive will be completed as soon as I'm incapacitated and can't think for myself."
c. "An advance directive will specify what I want done when I can no longer make de-cisions about health care."
d. "An advance directive will allow me to keep my money out of the reach of my family."
C
An advance directive is a written document prepared by a competent individual that specifies what, if any, extraordinary actions a person would want taken when he or she can no longer make decisions about personal health care. It does not address issues such as the client's resi-dence in his or her own home.
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The family members of an elderly patient are wondering why his "blood counts" are not rising after his last GI bleed. They state, "He has always bounced back after one of these episodes, but this time it isn't happening. Do you know why?" The nurse will respond based on which of the following pathophysiological principles?
A) "Everything slows down when you get older. You just have to wait and see what happens." B) "Due to stress, the red blood cells of older adults are not replaced as promptly as younger people." C) "The doctor may start looking for another cause of his anemia, maybe cancer of the bone." D) "Don't worry about it. We can always give him more blood."
When performing a mental status examination on an older adult client, the nurse discovers that the client is illiterate and only has a third-grade education. How should the nurse assess the client's cognition?
a. Have the client spell the word "world" backwards. b. Have the client spell the word "world" forwards. c. Ask the client to perform serial 7s. d. Instruct the client to state the days of the week backwards.
A patient is in the operating room holding area and tells the nurse that he changed his mind and does not want the procedure. Which of the following should the nurse do?
1. Contact the surgeon and implement steps to cancel the procedure. 2. Explain to the patient that he has already made his decision and cannot change his mind. 3. Ask the surgeon to explain to the patient why he needs the surgery. 4. Document that the preoperative anesthesia has made the patient confused.
The nurse is weighing and measuring a term newborn. Which findings would cause the nurse to conclude that the baby is suffering from asymmetrical intrauterine growth restriction (IUGR)?
A) Looks wasted and has poor skin turgor B) Is pale with loose, dry skin C) Has cracked and leathery skin D) Has very thin skin and has multiple visible veins