# A 78-year-old client with advanced dementia is admitted for aspiration pneumonia. The client is unable to communicate and has no advance directive. The healthcare team needs to identify the surrogate decision maker. Which actions should the nurse take? Select all that apply.

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=505781&lang=en  
> language: en  
> subject: Management of Care  
> category: MOC

## Question

A 78-year-old client with advanced dementia is admitted for aspiration pneumonia. The client is unable to communicate and has no advance directive. The healthcare team needs to identify the surrogate decision maker. Which actions should the nurse take? Select all that apply.

1

Verify the state-law surrogate hierarchy with the hospital's legal or ethics resource.

2

Ask the adult children whether the client completed any treatment-preference documents.

3

Designate the attending physician to serve as the client's surrogate decision maker.

4

Review prior records for documentation naming a healthcare agent or power of attorney.

5

Postpone decisions until the client recovers enough capacity to choose independently.

6

Contact the spouse and verify whether that person has priority under applicable state law.

## Explanation

When a client lacks decision-making capacity, the nurse should search for an already designated agent and follow applicable state law and facility policy. Reviewing prior records for a healthcare power of attorney and asking adult children about documents can identify an appointed decision maker. The hospital's legal or ethics resource can verify the jurisdiction's surrogate hierarchy, and the spouse should be contacted while the nurse confirms that person's legal priority. The attending physician is not automatically the surrogate, and necessary decisions should not be delayed while waiting for a client with advanced dementia to regain capacity.

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