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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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Choice A rationale

Histrionic personality disorder is characterized by a pervasive pattern of excessive emotionality and attention-seeking behavior. Individuals with this disorder often feel uncomfortable when not the center of attention and may use dramatic, theatrical, or seductive behaviors to attract others. They are not typically withdrawn or anxious in social settings.

Choice B rationale

Avoidant personality disorder is characterized by a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. The client's statements of becoming "extremely anxious in social gatherings" and never feeling "good enough" for coworkers are hallmark symptoms of this disorder. They actively avoid social situations to prevent rejection.

Choice C rationale

Obsessive-compulsive personality disorder is characterized by a preoccupation with orderliness, perfectionism, and mental and interpersonal control. Individuals with this disorder are often rigid and inflexible. They are not typically described as being socially anxious due to feelings of inadequacy, but rather due to a need for control.

Choice D rationale

Borderline personality disorder is characterized by a pervasive pattern of instability in interpersonal relationships, self-image, and emotions, and marked impulsivity. While individuals with this disorder may experience intense anxiety and fear of abandonment, their core features are related to instability, not a pervasive feeling of not being "good enough" in social settings. .

A. Protective environment B. Blood transfusion C. Iron supplementation D. Antibiotic continuation

Correct Answer is C

Explanation

Choice A rationale: A protective environment is typically indicated for immunocompromised clients, such as those with neutropenia or undergoing chemotherapy, not for uncomplicated anemia. The toddler’s white blood cell count is within the normal range of 5,000 to 10,000/mm³, and no evidence of infection risk or severe immunodeficiency is present. Pallor and low hemoglobin are consistent with iron deficiency anemia, which does not require isolation precautions unless additional hematologic compromise is identified.

Choice B rationale: Blood transfusions are reserved for cases of severe anemia with hemodynamic instability, cardiac compromise, or hemoglobin levels below 7 g/dL. This toddler’s hemoglobin is 8.1 g/dL, which while low, does not meet transfusion threshold in a stable, asymptomatic pediatric patient. Transfusion carries risks like iron overload and alloimmunization, making it inappropriate for mild to moderate anemia. Instead, correction through dietary modification and iron supplementation is preferred for age-related iron-deficiency anemia.

Choice C rationale: Iron supplementation is the standard therapy for iron deficiency anemia, especially in toddlers consuming excessive cow’s milk, which lacks iron and can cause occult intestinal blood loss. Hemoglobin of 8.1 g/dL is below the normal pediatric range of 9.5 to 14 g/dL, confirming anemia. Iron replenishment stimulates erythropoiesis by enabling hemoglobin synthesis. Supplementation corrects deficiency over time and should be paired with dietary education to limit milk to <24 oz/day and include iron-rich foods.

Choice D rationale: Continuing antibiotics is unnecessary unless there is ongoing infection. The toddler has recently completed antibiotic therapy for otitis media, and current symptoms do not suggest infection recurrence. Vital signs are stable and the white blood cell count is within normal limits (5,000–10,000/mm³), indicating no acute bacterial process. Antibiotic overuse may disrupt gut flora, impair iron absorption, and contribute to resistant bacterial strains, which is contraindicated in this clinical scenario.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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.

Correct Answer is B

Explanation

A nurse is assessing a 2-year-old male toddler in a pediatric clinic during a well-child checkup. Exhibits After reviewing the toddler’s current medical record, which of the following interventions should the nurse expect the provider to prescribe?

Correct Answer is C

Explanation

A nurse is inserting a short peripheral IV catheter for a client who requires IV fluids. Which of the following actions should the nurse take?

A nurse is caring for a client following an involuntary admission to an acute mental health facility. The client states, "I'm afraid they will give me drugs that put me to sleep.”. Which of the following statements should the nurse make?

A nurse is caring for a client who has a new prescription for spironolactone and reports that they forgot to tell the provider that they take over-the-counter supplements. The nurse should instruct the client to avoid which of the following supplements?

A nurse is assessing a client who has a sliding hiatal hernia. Which of the following findings should the nurse expect?

A nurse is preparing to administer medication to a client. Which of the following identifiers should the nurse use to identify the client?

A nurse is teaching the guardian of a newborn about car seat safety. Which of the following statements by the guardian indicates an understanding of the teaching?

A community health nurse is providing education to a group of older adults about immunizations. Which of the following immunizations should the nurse recommend?