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 D
Explanation
Choice A Reason:
Informing the provider of the delay in obtaining the type and cross-match is important for keeping the healthcare team informed. However, this action should follow the immediate step of obtaining the type and cross-match to ensure the client has compatible blood available for surgery. Communication with the provider is crucial but secondary to addressing the immediate need.
Choice B Reason:
Documenting the incident in the client’s medical record is necessary for maintaining accurate records and ensuring continuity of care. However, this action should be performed after the immediate need for obtaining the type and cross-match is addressed. Accurate documentation is essential but not the first priority in this situation.
Choice C Reason:
Preparing an incident report for risk management is important for identifying and addressing potential system issues that led to the oversight. However, this action is not the immediate priority. The primary focus should be on obtaining the type and cross-match to ensure the client’s safety during surgery. Incident reporting can be done after the immediate needs are met.
Choice D Reason:
Obtaining the client’s type and cross-match is the first action the nurse should take because it ensures that the client will have compatible blood available for transfusion if needed during surgery. This step directly addresses the immediate clinical need and prioritizes the client’s safety and readiness for surgery.
Correct Answer is A
Explanation
Choice A Reason:
Cranial nerve VII, also known as the facial nerve, is responsible for controlling the muscles of facial expression. When assessing this nerve, a nurse would expect to see symmetrical facial movements, such as a symmetrical smile. This indicates that the facial nerve is functioning properly on both sides of the face. Any asymmetry could suggest a problem with the facial nerve, such as Bell’s palsy or a stroke.
Choice B Reason:
The position of the tongue is controlled by cranial nerve XII, the hypoglossal nerve, not cranial nerve VII. The hypoglossal nerve is responsible for the movements of the tongue, and a midline position indicates normal function of this nerve. Therefore, this response is not relevant to the assessment of cranial nerve VII.
Choice C Reason:
Turning the head against resistance is a test for cranial nerve XI, the accessory nerve. This nerve controls the sternocleidomastoid and trapezius muscles, which are involved in head and shoulder movements. Assessing the ability to turn the head against resistance helps evaluate the function of the accessory nerve, not the facial nerve.
Choice D Reason:
Pupillary constriction in response to light is a function of cranial nerve III, the oculomotor nerve. This nerve controls the muscles that constrict the pupil in response to light, a reflex known as the pupillary light reflex. This response is not related to the function of cranial nerve VII.
