NCLEX UWorld (1823 Questions with 100% Correct Answers) complete solution guide

When do *advanced directives* go into effect? - when person is *unable to speak for him/herself* due to either: 1. *Mental Incapacity* - *coma *(GCS score ≤ 7) 2. *Aphasia* (≠as soon as signed; directives can always be changed later by person) SBAR Communication Framekwork Components - 1. *S* = Situation - what *prompted* the communication (eg *what* changes occurred) 2. *B* = Background - *pertinent information, relevant history, vital signs* 3. *A* = Assessment - nurse's assessment of the situation (*when* & *what changes* occurred) 4. *R* = Recommendation - *request* for *prescription* or *action* from HCP Appropriate order of actions when client found on floor - 1. *Assessment* of *physiological stability* (ABCs) 2. *Assessment* of *injuries* 3. *Moving client* 4. *Notifications* 5. *Documentation* Conditions of being *ineligible to leave AMA* - 1 *danger to self or others* 2. *lack of consciousness* 3. *Altered consciousness* 4. *Mental illness* 5. Being under *chemical influence* 6. *Court decision*