A client's adult child left the facility to go home and get the client's prescribed medications.

The client is visibly more relaxed and now speaking more openly to staff with improved eye contact.

The client reports they have lived with their adult child for the past several months due to their inability to care for themselves without assistance.

The client states their adult child "gets frustrated with me, but I understand why.

I move so slow and need help with everything.”. The client states they give their retirement income to their adult child to pay for their prescribed medication and household expenses, but they have no access to the bank account.

The client states their adult child makes "a few meals a week" and that there is little food in the house.

What should be the nurse's priority action based on this information?

Report suspected elder abuse to the appropriate authorities.

Ask the client's adult child about the client's financial situation.

Educate the client's adult child about the importance of nutrition.

Encourage the client to discuss their frustrations with their adult child.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Based on the client's statements, there is strong evidence of neglect and potential exploitation. Neglect is indicated by the inadequate food supply and minimal meal preparation. Financial exploitation is suggested by the client's lack of access to their retirement income, despite it being used for their care. This situation poses a serious risk to the client's well-being, triggering the nurse's ethical and legal duty to report suspected elder abuse to the appropriate authorities.

Choice B rationale

While gathering more information is often a good practice, directly questioning the adult child about financial matters could escalate the situation and potentially put the client at further risk. The primary responsibility of the nurse in this scenario is to ensure the client's safety, and the existing information is sufficient to warrant a report. The client has already provided a detailed account of the financial arrangement and their lack of access to funds, which is a key indicator of exploitation.

Choice C rationale

Educating the adult child about nutrition, while potentially helpful in some circumstances, does not address the immediate and serious issues of neglect and financial exploitation. The client's safety is the priority. Focusing solely on education ignores the broader pattern of abuse and the client's vulnerability, which requires a more direct and protective intervention.

Choice D rationale

Encouraging the client to speak with their adult child may place them in a more vulnerable position and could increase the risk of retaliation or further neglect. The client has already expressed an understanding of their adult child's frustration, and this approach fails to address the power imbalance and exploitative nature of the relationship. It is not an appropriate or safe intervention in a situation of suspected abuse. *.

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Correct Answer is C

Explanation

Choice A rationale

Losartan is an angiotensin II receptor blocker (ARB) which works by preventing angiotensin II from binding to its receptors in vascular smooth muscle, thereby causing vasodilation and lowering blood pressure. Hypertension is the condition losartan is prescribed to treat, not an adverse effect, because its mechanism directly counteracts the vasoconstrictive effects of angiotensin II. The intended therapeutic effect is a reduction in systemic vascular resistance and blood pressure.

Choice B rationale

Double vision, also known as diplopia, is not a recognized common or significant adverse effect of losartan. The mechanism of action of losartan primarily targets the renin-angiotensin-aldosterone system (RAAS), influencing blood pressure regulation and fluid balance, not directly affecting the central nervous system or ocular motor function. This symptom would be more indicative of neurological or ophthalmological issues unrelated to the medication's primary action.

Choice C rationale

Dizziness is a common adverse effect of losartan. This is a direct consequence of its therapeutic action, which is to lower blood pressure. The resulting vasodilation and reduced blood pressure can lead to orthostatic hypotension, causing feelings of lightheadedness or dizziness, especially when a person changes positions, like standing up. The brain's reduced perfusion pressure triggers this sensation as a physiological response.

Choice D rationale

Hyperactivity is not an expected adverse effect of losartan. The medication primarily affects the cardiovascular system by modulating the RAAS to lower blood pressure. It does not have known stimulant properties that would lead to increased energy, restlessness, or hyperactivity. Such a finding would likely be attributed to other factors or a different underlying condition, not the pharmacological action of this medication. *.

A. Crusting along the incision line. B. Temperature of 37.2° C (99° F). C. Pink coloration of the incision line. D. Swelling extending 3.8 cm (1.5 in) from the incision.

Correct Answer is D

Explanation

Choice A rationale

Crusting along the incision line is the result of dried serous fluid and blood, which is a normal part of the wound healing process during the inflammatory phase. This finding alone is not indicative of a surgical site infection, which is characterized by other signs.

Choice B rationale

A temperature of $37.2^\circ C$ ($99^\circ F$) is within the normal range for body temperature ($36.1^\circ C$ to $37.2^\circ C$ or $97^\circ F$ to $99^\circ F$). An elevated temperature, specifically a fever, is a systemic sign of infection. A low-grade fever might be a subtle sign, but this temperature is not high enough.

Choice C rationale

Pink coloration of the incision line is a normal finding in the early stages of wound healing, representing angiogenesis, the formation of new blood vessels. This process is crucial for tissue repair and does not indicate a surgical site infection, which is typically characterized by erythema and warmth.

Choice D rationale

Swelling, or edema, is a classic sign of inflammation and infection. While some minor swelling is normal, swelling that extends significantly beyond the wound margins, such as 3.8 cm (1.5 in), indicates a heightened inflammatory response potentially due to bacterial proliferation and infection. *.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is taking losartan. Which of the following findings should the nurse identify as an adverse effect of this medication?

Correct Answer is C

Explanation

A nurse is replacing the dressing for a client who is postoperative following thoracic surgery. When assessing the surgical wound, which of the following findings should the nurse identify as an indication of infection?

Correct Answer is D

Explanation

A nurse is planning assignments for the upcoming shift. Which of the following tasks should the nurse delegate to an assistive personnel?

A nurse is assessing a client who states that she becomes extremely anxious in social gatherings. She tells the nurse that she never feels "good enough" for her coworkers. The nurse should identify that these findings can indicate which of the following personality disorders.

A nurse is teaching a client who has a new prescription for levothyroxine about thyrotoxicosis. The nurse should instruct the client to monitor and report which of the following findings?

A nurse is planning care for an older adult client who has dementia and a nutritional deficit. Which of the following actions should the nurse plan to take?

A nurse is preparing regular and NPH insulin in the same syringe for a client who has diabetes mellitus. Which of the following actions should the nurse take?

A nurse is caring for a client who has schizophrenia. The client states, "The voices in my head are driving me crazy.”. Which of the following Questions should the nurse ask?

A nurse is assessing a client who has schizophrenia prior to administering the client's next dose of clozapine. Which of the following findings should the nurse report to the provider?

A nurse is providing discharge teaching to a client who has GERD. Which of the following information should the nurse include?