Your client is in the special care area of your hospital with multiple trauma and severe bodily burns. This 45 year old male client has an advance directive that states that the client wants all life saving measures including cardiopulmonary resuscitation and advance cardiac life support, including mechanical ventilation. As you are caring for the client, the client has a complete cardiac and respiratory arrest. This client has little of no chance for survival and they are facing imminent death according to your professional judgement, knowledge of pathophysiology and your critical thinking. You believe that all life saving measures for this client would be futile. What is the first thing that you, as the nurse, should do?

Correct Answer: A

Rationale: In this scenario, the correct action for the nurse to take is to choose option A) Call the doctor and advise them that the client's physical status has significantly changed and that they have just had a cardiopulmonary arrest. This is the most appropriate response because it aligns with the principles of family-centered care and ethical nursing practice. Calling the doctor immediately ensures that the healthcare team is alerted to the change in the client's condition and can provide guidance on the next steps. In situations where the nurse believes that further life-saving measures would be futile and not in the best interest of the patient, it is crucial to involve the healthcare provider in decision-making to ensure that the client receives appropriate care and support at the end of life. Option B is incorrect because initiating cardiopulmonary resuscitation and other emergency life-saving measures would go against the client's advance directive, which clearly states the client's wishes for end-of-life care. Option C is also incorrect as it does not prioritize the immediate medical intervention that the client requires in this critical situation. Option D is incorrect as it does not address the urgent need to involve the healthcare team in the decision-making process. Educationally, this scenario highlights the importance of understanding and respecting advance directives, effective communication within the healthcare team, and advocating for the best interest of the client in end-of-life care situations. It underscores the significance of timely and appropriate actions in critical care settings, emphasizing the nurse's role in facilitating collaborative decision-making for optimal patient outcomes.

Correct Answer: D

Rationale: In the context of family-centered care in nursing, obtaining informed consent is a critical aspect of respecting patients' autonomy and involving them in their healthcare decisions. The correct answer, D, "When the procedure or treatment will be done," is not an essential minimal component of the teaching prior to obtaining informed consent. While it is important for patients to understand the timeline of their care, the timing of the procedure is not a key factor in ensuring informed decision-making. Options A, B, and C are essential components of the teaching required for informed consent. A) The purpose of the proposed treatment or procedure is crucial for patients to understand why a particular intervention is being recommended. B) Discussing the expected outcomes of the proposed treatment or procedure helps patients make an informed decision about their care. C) Knowing who will perform the treatment or procedure is essential for patients to have confidence in the healthcare team and understand who will be involved in their care. In an educational context, it is important for nursing students to grasp the significance of each component of the informed consent process to ensure that patients are fully informed and engaged in their healthcare decisions. Understanding the rationale behind each element helps students provide comprehensive and patient-centered care, promoting trust and collaboration between healthcare providers and patients.

Correct Answer: B

Rationale: In the scenario of transferring a paralyzed client from the bed to a chair for the first time with the assistance of another person, the best and safest option is to use a mechanical lift (Option B). Using a mechanical lift is the safest choice because it provides optimal support and minimizes the risk of injury to both the client and the caregivers. It allows for a controlled and smooth transfer, especially when dealing with a paralyzed client who may have limited mobility and muscle strength. Using a slide board (Option A) may not provide enough support for the client during the transfer, increasing the risk of falls or injuries. A gait belt (Option C) is suitable for clients who can bear some weight and participate in the transfer process, which may not be the case for a paralyzed client. Notifying the client's doctor (Option D) without attempting a safe transfer first is not appropriate as it delays necessary care and does not address the immediate need for transferring the client. In an educational context, understanding the appropriate transfer techniques is crucial for nursing students to ensure the safety and well-being of their clients. It is essential to prioritize proper body mechanics and equipment use to prevent accidents and promote effective patient care.

Correct Answer: A

Rationale: In this scenario, determining the expected date of delivery (EDD) based on the client's last menstrual period (LMP) is a fundamental aspect of providing family-centered care in nursing. The correct answer is A) 7/7/2017. The EDD is calculated by adding 280 days (40 weeks) to the first day of the woman's LMP. In this case, if the LMP was on 10/20/2016, adding 280 days brings us to 7/7/2017. This calculation is based on the average length of a woman's menstrual cycle (28 days) and assumes a regular 28-day cycle. Option B) 8/7/2017 is incorrect because it adds an extra month to the calculated EDD, which is not accurate based on the standard 40-week gestation period. Option C) 6/7/2017 is incorrect as it subtracts a month from the calculated EDD, which would result in an EDD that is too early. Option D) 8/1/2017 is incorrect as it is earlier than the accurate calculated EDD, which would result in an incorrect estimation of the pregnancy timeline. Understanding how to calculate the EDD is crucial for nurses providing prenatal care as it helps in monitoring the progress of the pregnancy, identifying any deviations from the expected timeline, and planning for the client's care accordingly. By mastering this skill, nurses can offer comprehensive and personalized care to expectant mothers and their families, aligning with the principles of family-centered care.

Correct Answer: A

Rationale: In the context of family-centered care in nursing, a comprehensive health assessment is crucial for gathering essential information about the patient's health status. Option A, which includes a complete medical history, a general survey, and a complete physical assessment, is the correct choice. A complete medical history helps in understanding the patient's past and current health issues, while a general survey provides an overall assessment of the patient's appearance and behavior. A complete physical assessment allows the nurse to examine all body systems thoroughly, ensuring a holistic understanding of the patient's health. Options B, C, and D are incorrect because they either lack components essential for a comprehensive assessment or include unnecessary elements that do not contribute significantly to the overall health evaluation. Focused assessments may miss important details, and additional interviews beyond the client and significant other may not always be necessary, making options B, C, and D less comprehensive. In an educational context, understanding the components of a comprehensive health assessment is fundamental for nursing students. It ensures that nurses gather accurate and relevant information to provide effective patient care. By choosing the correct option, students learn the importance of a thorough assessment process in delivering high-quality, patient-centered care.