Author Question: The nurse working on a medical unit is admitting a client diagnosed with heart failure. During the ... (Read 109 times)

natalie2426 · **on:** Jun 25, 2018

The nurse working on a medical unit is admitting a client diagnosed with heart failure. During the admission process, the client states, I do not want to be put on a ventilator because I had to watch my mother die on a ventilator.

I want information on making out a will. When planning care for this client, which intervention is the most appropriate?
A) Educate the client on the process and purpose of a living will and arrange for one to be created should the client choose to do so.
B) Encourage the client to allow for mechanical ventilation.
C) Educate the client on the purpose of mechanical ventilation.
D) Refer the client to a therapist to deal with the death of her mother.

Question 2

The nurse is developing a plan of care for a client who is at risk for falls. Which interventions would be appropriate for the nurse to include in the plan of care?

Select all that apply.
A) Apply physical restraints if the client gets out of bed.
B) Assess the client's vision and make sure he is utilizing any prescribed eyewear.
C) Utilize side rails on client beds.
D) Keep frequently used items within easy reach.

joneynes · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Answer: A

Although it is appropriate to educate the client on mechanical ventilation, the client asked for information on making out a living will. It would be most appropriate at this time for the nurse to educate the client on the process and purpose of a living will and arrange for one to be created should the client choose to do so. The nurse should not attempt to convince the client to allow for medical treatment. The nurse may educate the client on a medical treatment. There is no indication that this client needs therapy.

Answer to Question 2

Answer: B, C, D

Assessing the client's vision and making sure he is utilizing any prescribed eyewear is an appropriate action. Poor and blurry vision increases the client's risk of falling. Utilizing side rails on the client bed to prevent falls while the client is sleeping is an appropriate intervention. Furthermore, it is appropriate to keep frequently used items within easy reach in an effort to prevent falls. It is not appropriate for the nurse to apply physical restraints if client gets out of bed. The nurse could include in the plan of care to apply physical restraints only when absolutely necessary for the client's safety and only by physician's order.