An RN’s current patient and family have presented her with an ethical dilemma. What is the first step the RN should take to find a workable solution to the problem?

Correct Answer: B

Rationale: The correct answer is **B: Assessment** because it is the foundational step in any nursing process, especially when addressing ethical dilemmas. Ethical dilemmas in nursing often involve complex, nuanced situations where multiple perspectives, values, and potential outcomes must be carefully considered. Assessment involves gathering all relevant information—medical, psychosocial, cultural, and ethical—to fully understand the context of the dilemma. This includes reviewing the patient’s medical history, their expressed wishes (if possible), the family’s concerns, legal considerations, and institutional policies. Without a thorough assessment, any subsequent actions could be misguided, ineffective, or even harmful. Ethical decision-making frameworks, such as the Four-Box Model (medical indications, patient preferences, quality of life, and contextual features), rely on comprehensive data collection first. Only after this can the nurse proceed to analyze, plan, and implement a solution. **A: Planning** is incorrect because it is a premature step if the nurse has not yet assessed the full scope of the dilemma. Planning involves developing a strategy to address the problem, but without a clear understanding of the patient’s condition, values, and the ethical conflict at hand, any plan would lack a solid foundation. For example, if the dilemma involves end-of-life care, the nurse cannot plan whether to advocate for palliative measures or continued treatment without first assessing the patient’s prognosis, advance directives, and family dynamics. Planning without assessment risks imposing solutions that do not align with the patient’s best interests or legal/ethical standards. **C: Evaluation** is incorrect because it occurs after actions have been taken, not at the outset of addressing an ethical dilemma. Evaluation involves reviewing the outcomes of implemented interventions to determine their effectiveness. In this scenario, no interventions or decisions have yet been made, so evaluating at this stage would be illogical. For instance, if the dilemma involves a family’s disagreement over a patient’s treatment, evaluating outcomes before even understanding the conflict would skip critical steps like clarifying misunderstandings or consulting ethics committees. Evaluation is essential but belongs at the end of the process, not the beginning. **D: Implementation** is incorrect because it assumes the nurse already has a clear course of action, which is impossible without first assessing the situation. Implementation involves executing a plan, but in an ethical dilemma, the plan itself must be carefully constructed based on gathered data. Jumping to implementation could lead to actions that violate patient autonomy, professional ethics, or legal standards. For example, if a family insists on a treatment the patient previously refused, implementing their demands without assessing the patient’s documented wishes or capacity would be unethical. Implementation relies on prior steps—assessment, analysis, and planning—to ensure the action is justified and appropriate. In summary, assessment is the critical first step because it ensures the nurse has all necessary information to navigate the ethical dilemma thoughtfully and systematically. Skipping this step undermines the integrity of the entire decision-making process, potentially leading to poor outcomes for the patient and family. The other choices—planning, evaluation, and implementation—are vital components of the nursing process but are only effective when built upon a thorough assessment.

Correct Answer: D

Rationale: A violation of the nurse practice act falls under the category of tort. Tort refers to civil wrongs that cause harm or loss to another person, and a violation of the nurse practice act can result in a civil lawsuit against the nurse for negligence or malpractice. Choices A, B, and C are incorrect because a violation of the nurse practice act does not fall under juvenile offenses, felonies, or misdemeanors, but rather under civil wrongs known as torts.

Correct Answer: C

Rationale: Let’s analyze each choice in detail to understand why **C** is correct and the others are not. **Choice C: A DNR order can be written after the health-care provider has discussed it with the client and family.** This is the correct answer because it accurately reflects the ethical and legal process of establishing a DNR order. A DNR (Do Not Resuscitate) order is a medical directive that prevents healthcare providers from performing CPR or other life-sustaining measures if the patient's heart stops or they stop breathing. The decision must involve **informed consent**, meaning the healthcare provider (physician, nurse practitioner, or other authorized professionals depending on jurisdiction) must discuss the implications, benefits, and risks with the patient (if competent) and/or their legal surrogate or family. This ensures the patient's autonomy and aligns with medical ethics, including respect for patient wishes and shared decision-making. **Why other choices are incorrect:** **Choice A: When a heart ceases to beat, the client is pronounced clinically dead.** This is incorrect because it misrepresents the definition of clinical death. Clinical death is determined by **irreversible cessation of circulatory and respiratory functions** *or* irreversible cessation of all brain activity (brain death). A stopped heartbeat alone does not always mean clinical death—CPR or defibrillation can sometimes restore circulation. Additionally, the question focuses on DNR discussions, not the criteria for declaring death. This choice is irrelevant to the client’s question about DNR orders. **Choice B: Physicians must write do not resuscitate (DNR) orders.** This is incorrect because it overgeneralizes who can write a DNR order. While physicians often write DNR orders, **other authorized healthcare providers** (such as nurse practitioners or physician assistants, depending on state or institutional policies) may also be legally permitted to do so. The key requirement is that the decision follows informed discussions with the patient/family, not strictly that a physician must be the one to document it. **Choice D: A DNR requires a court decision.** This is incorrect because DNR orders do not typically involve courts unless there is a **legal dispute** (e.g., family members disagreeing with the decision). Normally, DNR decisions are made by the healthcare team in collaboration with the patient or their legally designated decision-maker (e.g., healthcare proxy, next of kin). Courts only intervene in exceptional cases where conflicts arise or if the patient lacks decision-making capacity without a clear surrogate. Implying that a court must always be involved is misleading and could unnecessarily complicate the process for patients and families. **Summary:** The correct answer (**C**) emphasizes **patient-centered communication** and the legal-ethical process of DNR orders, while the incorrect choices either misrepresent medical definitions (A), oversimplify roles (B), or introduce unnecessary legal hurdles (D). Understanding these distinctions ensures accurate patient education and upholds ethical standards in end-of-life care.

Correct Answer: D

Rationale: Option D is correct because it accurately describes the primary purpose of an advance directive in a healthcare context. An advance directive is a legal document that allows individuals to specify their preferences for medical treatment and appoint a healthcare surrogate (also called a healthcare proxy or agent) to make decisions on their behalf if they become incapacitated. This surrogate is responsible for communicating and enforcing the patient’s documented wishes, ensuring autonomy is preserved even when the patient cannot speak for themselves. This aligns with ethical principles of patient-centered care and respects the individual’s right to self-determination in medical decisions. Option A is incorrect because it misrepresents the role of nurses under the Patient Self-Determination Act (PSDA). While the PSDA mandates that healthcare institutions (such as hospitals) inform patients of their right to create an advance directive upon admission, it does not place this responsibility solely on nurses. Nurses may facilitate these discussions, but the legal obligation lies with the institution. Additionally, the PSDA does not require nurses to directly educate clients about advance directives—it ensures that institutions provide written information, not individual providers. Option B is incorrect because it conflates advance directives with financial decision-making authority. Advance directives pertain exclusively to healthcare decisions, not financial or legal matters. Financial decisions for an incapacitated individual are typically handled through separate legal instruments, such as a durable power of attorney for finances or a conservatorship. Including this in a discussion with nurse graduates would create confusion about the scope of advance directives, which are strictly healthcare-related. Option C is incorrect because it inaccurately describes the function of a living will. A living will is a type of advance directive that outlines an individual’s preferences for specific medical treatments (e.g., life support, artificial nutrition) but does not designate a decision-maker. The confusion arises from mixing the concepts of a living will (which states wishes) and a healthcare surrogate designation (which appoints a person to make decisions). A living will is static, while a surrogate can adapt decisions to unanticipated circumstances, making this distinction critical for nurse graduates to understand. Clarity on these distinctions is essential for nurses, as they often serve as advocates and educators for patients navigating advance care planning. Misinformation could lead to legal or ethical breaches, such as failing to honor a patient’s true wishes or improperly guiding families during crises. The correct answer (D) emphasizes the surrogate’s role, which is central to the practical application of advance directives in clinical settings.

Correct Answer: C

Rationale: A caring leader embodies traits such as respecting coworkers as unique individuals and showing empathy towards their needs and concerns. These qualities are essential for fostering a supportive and compassionate work environment, where team members feel valued and understood. Choice A is incorrect because a caring leader balances serving others with effective leadership, not prioritizing one over the other. Choice B, though important, focuses solely on recognizing emotions and does not encompass the broader traits of caring leadership. Choice D is also important but does not capture the essence of respecting individuals and empathizing with their needs, which are core aspects of caring leadership.