A chronically depressed older male resident of a long-term care facility has become more reclusive and today refuses to leave his room. His family has moved away and are unable to visit as much as in the past. Which comment by the practical nurse (PN) is likely to be most helpful to this client?

“Come into the recreation area. We have your favorite card game and I will play it with you."

"Why do you want to stay in your room today?”

"I know you are sad about not seeing your family as often, but they are visiting as much as they can.”

d “May I sit with you for a while?"

Answer and Explanation

The Correct Answer is D

d. “May I sit with you for a while?"

This comment shows empathy, respect, and support for the client, without being intrusive or judgmental. The PN acknowledges the client's feelings and oﬀers companionship, which can help reduce isolation and loneliness.

The other options are not correct because:

This comment may be perceived as coercive or dismissive of the client's feelings, as it tries to persuade the client to do something he does not want to do or enjoy.
This comment may be perceived as accusatory or interrogatory, as it questions the client's decision or motive for staying in his room.
This comment may be perceived as minimizing or invalidating the client's feelings, as it implies that the client should not be sad or that his family is doing enough for him.

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Correct Answer is C

Explanation

A) Incorrect - Requesting the client to lie still may be relevant for certain assessments, but it is not specific to the situation described in the question.
B) Incorrect - Inquiring about episodes of sundowning is more relevant for clients with cognitive impairment and is not directly related to the client's weight loss and decreased energy and appetite.
C) Correct - Questioning the client about the frequency of falls is important, as falls can contribute to weight loss, decreased energy, and appetite changes in older adults.
D) Incorrect - Assisting the client with clarifying values about end-of-life care is a valuable nursing intervention but is not the priority in this assessment scenario.

A. The lab results indicate myocardial damage, and the client is at risk for cardiac dysrhythmias B. The client is at risk for pulmonary embolism, and lifestyle modifications need to be implemented. C. The client is at risk for recurrent long-term angina pain and subsequent myocardial infarction (MI). D. The lab results indicate risk factors for transient ischemic atack (TIA), and neurological vital signs should be monitored.

Correct Answer is A

Explanation

Troponin I and CK-MB are cardiac enzymes that are released into the bloodstream when the heart muscle is injured or necrotic. Elevated levels of these enzymes indicate that the client has suﬀered a myocardial infarction (MI) or heart atack. The damaged heart tissue can impair the electrical conduction system of the heart and cause abnormal heart rhythms or dysrhythmias, which can be life-threatening. The PN should monitor the client's cardiac status closely and report any changes to the charge nurse.

The other options are not correct because:

The client is not at risk for pulmonary embolism, which is a blockage of a pulmonary artery by a blood clot or other material. Pulmonary embolism does not cause elevated cardiac enzymes, but it can cause chest pain, shortness of breath, and hypoxia.
The client is not at risk for recurrent long-term angina pain, which is chest pain caused by reduced blood ﬂow to the heart muscle due to narrowed or blocked coronary arteries. Angina pain does not cause elevated cardiac enzymes, but it can be a warning sign of an impending MI.
The lab results do not indicate risk factors for transient ischemic atack (TIA), which is a temporary interruption of blood ﬂow to a part of the brain due to a clot or plaque. TIA does not cause elevated cardiac enzymes, but it can cause neurological symptoms such as weakness, numbness, or speech difficulties.

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A chronically depressed older male resident of a long-term care facility has become more reclusive and today refuses to leave his room. His family has moved away and are unable to visit as much as in the past. Which comment by the practical nurse (PN) is likely to be most helpful to this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing a functional assessment on an older client who lost five pounds (2.27 Kg) of weight since the last visit 12 weeks ago, and who reports a decrease in energy and appetite. Which action should the nurse include during the assessment?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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