An adult who lacks decision-making capacity has an advance directive naming the spouse as health care agent. An adult child asks the nurse to ignore the spouse and make a different plan. No immediate emergency is present. Complete the management-of-care statement.
Drop-down Rationale
Choose your responses, then check the answer.
Explanation
The nurse first verifies the advance directive, the documented loss of decision-making capacity, and the identity and authority of the named health care agent under applicable law and policy. Decisions should be discussed with the authorized representative using the client's expressed wishes, values, and best interests rather than family hierarchy or staff preference. If conflict persists, the nurse maintains current safe care, communicates the dispute to the provider and nursing leadership, documents objective facts, and obtains ethics, legal, or risk-management support according to policy. The nurse should not conceal the directive, choose a surrogate independently, or allow a nonurgent family dispute to bypass the established process.
Correct Answer Verify the directive and the named agent's authority, center decisions on the client's documented wishes and values, and escalate an unresolved conflict through the provider, nursing leadership, and ethics or legal resources according to policy.
Why It Fits An advance directive is part of the plan of care when the client lacks capacity. The nurse protects the client's voice by confirming the legal and clinical facts before treating any relative's preference as controlling.
Clinical Picture There is time to verify the document and obtain the appropriate team review. Current safe care continues while the nonurgent dispute is resolved through an authorized process.
Memory Link Verify the document, identify the agent, follow the client's voice, escalate the conflict.
NCLEX Rule The nurse integrates advance directives into care but does not independently make legal determinations or let family pressure erase documented client preferences.
Why the Alternatives Fail Choosing the loudest relative ignores the established representative. Hiding the directive blocks informed team review. Stopping all care without an applicable decision or order can harm the client, while waiting silently leaves the conflict unresolved.
Source
1CMS Hospital Patients' Rights to Representatives
22026 NCLEX-RN Test Plan
The directive is available in the record, but the team has not yet confirmed that it applies to the current decision. The nurse follows applicable law and facility policy, preserves the client's known values, and does not personally decide which family member should prevail.
Decision-making capacity — A clinical determination of whether a person can understand relevant information, appreciate consequences, reason about options, and communicate a choice for a specific decision.
Health care agent — A person designated through an applicable legal process to make health care decisions when the client cannot do so.
Advance directive — A document or instruction that communicates future health care preferences or identifies a representative, interpreted under applicable law and policy.