A nurse is providing information to a client about durable power of attorney. The nurse should include that durable power of attorney is enforceable under which of the following conditions?
The client is incapable of providing self-care.
The client is terminally ill.
The client is unable to express their wishes.
The client has refused treatment.
The Correct Answer is C
Choice A Reason:
The condition that the client is incapable of providing self-care does not necessarily make a durable power of attorney enforceable. While incapacity can be a factor, the key aspect is the client’s ability to make decisions. A durable power of attorney becomes effective when the client is unable to make their own decisions, not merely when they are unable to provide self-care.
Choice B Reason:
Being terminally ill does not automatically make a durable power of attorney enforceable. The enforceability of a durable power of attorney is based on the client’s decision-making capacity. While terminal illness might lead to incapacity, it is the inability to make decisions that triggers the use of the durable power of attorney.
Choice C Reason:
A durable power of attorney is specifically designed to be enforceable when the client is unable to express their wishes. This legal document allows the designated agent to make decisions on behalf of the client when they are incapacitated and unable to communicate their preferences. This ensures that the client’s affairs are managed according to their wishes, even when they cannot express them.
Choice D Reason:
The refusal of treatment by the client does not make a durable power of attorney enforceable. The enforceability is related to the client’s capacity to make decisions. If a client is still capable of making informed decisions, even if they refuse treatment, the durable power of attorney does not come into effect.
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View Related questions
Correct Answer is C
Explanation
Choice A Reason
Lifting the client to the bed with assistance is not recommended during a seizure. Moving the client can increase the risk of injury to both the client and the nurse. The primary focus should be on ensuring the client’s safety by preventing injury from nearby objects and allowing the seizure to run its course.
Choice B Reason
Turning the client onto their back is not advisable during a seizure. This position can increase the risk of airway obstruction and aspiration. Instead, the client should be turned onto their side to maintain an open airway and allow any secretions to drain from the mouth, reducing the risk of aspiration.
Choice C Reason
Clearing the nearby area of furniture is the most appropriate action. This helps to prevent the client from injuring themselves on hard or sharp objects during the seizure. Ensuring a safe environment is a key priority in managing a seizure, as it minimizes the risk of physical harm.
Choice D Reason
Placing a tongue depressor in the client’s mouth is an outdated and dangerous practice. It can cause injury to the client’s teeth, mouth, or airway. There is also a risk of the client biting down and breaking the depressor, leading to choking hazards. Modern seizure management guidelines strongly advise against placing any objects in the client’s mouth during a seizure.
Correct Answer is B
Explanation
Choice A Reason:
Dissociation is a defense mechanism where a person disconnects from their thoughts, feelings, or sense of identity. It often occurs in response to trauma or extreme stress, allowing the individual to distance themselves from the reality of the situation. In this case, the client is not showing signs of dissociation, such as feeling detached from reality or experiencing memory gaps. Instead, they are avoiding the reality of their partner’s condition.
Choice B Reason:
Denial is a defense mechanism where a person refuses to accept the reality of a situation to avoid dealing with painful emotions. The client’s statement about planning a trip despite their partner’s terminal condition indicates that they are not acknowledging the severity of the situation. This refusal to accept reality helps them cope with the emotional distress associated with their partner’s impending death.
Choice C Reason:
Regression involves reverting to behaviors from an earlier stage of development when faced with stress. This might include actions like thumb-sucking, bed-wetting, or other childlike behaviors. The client’s statement does not indicate a return to earlier developmental behaviors but rather a refusal to accept the current reality.
Choice D Reason:
Displacement is a defense mechanism where negative emotions are redirected from their original source to a less threatening target. For example, someone might take out their frustration with their boss on a family member. In this scenario, the client is not redirecting their emotions but rather avoiding the reality of their partner’s condition.