Upon admitting a client to the hospital, the nurse receives an ...

[littleanan]

Upon admitting a client to the hospital, the nurse receives an advance health care directive to include in the medical record. The directive is witnessed by two of the client's three children. How does the nurse interpret this information?
 
  1. This advance directive may not be legal as children cannot witness advance directives in some states.
  2. Having the children's signatures on the advance directive is good because it indicates they agree with the client's wishes.
  3. The advance directive cannot be honored unless it is witnessed by all three children.
  4. In order to be valid, the advance directive must be witnessed by the client's physician.

Question 2

The client has a documented advance health care directive that indicates that no resuscitative measures should be employed in the event of a respiratory or cardiac arrest.
 
  The client begins to exhibit severe dyspnea and air hunger and says, Please do something, I can't breathe. What action should be taken by the nurse?
  1. Offer the client comfort measures until death occurs.
  2. Call the client's physician for direction.
  3. Initiate resuscitative measures.
  4. Check the medical record to ascertain the terms of the directive.

[reelove4eva]

Answer to Question 1

Correct Answer: 1
Rationale: The nurse must be certain that the advance directive is a legal document. In some states, relatives, heirs, and physicians cannot witness an advance directive. This is to prevent potential abuse of power.

Answer to Question 2

Correct Answer: 3
Rationale 1: Just offering comfort measures until the client dies is ignoring the client's wishes.
Rationale 2: There is no need to call the physician for direction, as the client has clearly given the nurse direction.
Rationale 3: This client has the right to change decisions about resuscitation, and has asked for help. The nurse should initiate resuscitative measures.
Rationale 4: The nurse should have already known the terms of the directive and would not have time to seek clarification at this point.

[littleanan]

TYSM

[ktidd]

Excellent