Bertha Klein, who is 70-years-old, suffered a stroke a year ago. She remains weak, and she hasright-sided paralysis and dysphagia. Her husband, Frank, has been caring for her at home. A home health nurse visits every other day and the Kleins' synagogue has been providing one meal a day. The Kleins' daughter, Carol, lives several states away with her husband and their three children, who are ages 15, 8, and 3.Bertha was sitting upright while Frank fed her broth from chicken noodle soup. She started spitting out the broth and turning blue around her mouth. Frank stopped feeding her and patted her back forcefully. Bertha was able to catch her breath and the blueness resolved. Two days later, Frank tells the home health nurse about the incident during a scheduled visit. The nurse notices that Bertha’s level of consciousness (LOC) has declined.1.Which assessment should be done immediately?A.Determine Frank’s knowledge about feeding a dysphagic person.B.Auscultate Bertha’s lungs for adventitious breath sounds.C.Assess Bertha’s LOC with the mini-mental status exam.D.Determine Bertha’s ability to swallow liquids.Correct Answer: B, Bertha’s lungs should be assessed immediately for adventitious breath sounds since she is at risk for aspiration pneumonia secondary to the chocking incident.Incorrect Rationale: A, This may be needed later, but it is not an immediate need.C, While decreased mental clarity may be a sequellae of decrease oxygen to the brain, her level of consciousness makes it impossible to administer this exam.D, While this is an important assessment parameter, another assessment is of higher priority.The home health nurse reports the following assessment findings to the healthcare provider (HCP): oral temperature 102˚ F and diminished breath sounds with crackles in the right lung. The HCP admits Mrs. Klein to the acute care facility with the diagnosis of aspiration pneumonia.Mrs. Klein is disoriented when she is admitted to the hospital. 2.During the admission procedure, what is the nurse’s responsibility regarding advance directives?Correct Answer: A, The Patient Self-Determination Act (1991) requires healthcare instructions to providewritten information concerning the client’s rights to refuse treatment and formulate advance directives. The nurse should ask Mr. Klein if his wife has completed a living will and a durable power of attorney.Incorrect Rationale: B, The PSDA does not require a client to have a living will.