Try Naxlex NCLEX-RN (Free-Trial)

A nurse in an emergency department is caring for a client. Nurses' Notes.

1200:.

Client is an 82-year-old male who presents with his adult child for evaluation of right arm pain after a fall. Client noted to have several superficial abrasions on right forearm and elbow. Also has numerous bruises in various stages of healing on arms and upper chest. Client rates pain in right lower forearm an 8 on a 0 to 10 pain scale and is not moving the arm.

1210:.

Client noted to keep head down and makes limited eye contact. Speaks very softly and looks at adult child before answering interview questions. Has strong body odor and clothes are unclean. Client's adult child answers most questions. Client grimacing and guarding right arm.

Client weighed, is 56.2 kg (124 lb) and 175 cm (69 in) tall. BMI 18.3.

1230:.

Client's adult child left facility to go home and get the client’s prescribed medications. Client visibly more relaxed and now speaking more openly to staff with improved eye contact. Client reports that he has lived with his adult child for the past several.

Vital Signs. 1200:.

Temperature 36.7° C (98° F). Heart rate 96/min.

Blood pressure 142/96 mm Hg. Respiratory rate 16/min.

SpO2 97% on room air.

The nurse is preparing to speak to the facility's Social Worker about the client's condition.

Select the 5 findings the nurse should plan to include in the report.

ECG results.

Client's report of lack of food in home.

client's report of lack of access to bank accounts.

Clients avoidance of eye contact.

Clients report of weight loss.

Numerous bruises in various stages of healing.

Answer and Explanation

Correct Answer : B,C,D,E,F

Answer is B, C, D, E, F. These are the findings that suggest possible elder abuse or neglect.

B: Client’s report of lack of food in home. This may indicate neglect by the adult child who is supposed to provide adequate nutrition for the client.
C: Client’s report of lack of access to bank accounts. This may indicate financial abuse by the adult child who is controlling the client’s money without his permission.
D: Client’s avoidance of eye contact. This may indicate emotional abuse by the adult child who is intimidating or threatening the client.
E: Client’s report of weight loss. This may indicate neglect by the adult child who is not meeting the client’s basic needs or physical abuse by the adult child who is causing bodily harm to the client.
F: Numerous bruises in various stages of healing. This may indicate physical abuse by the adult child who is hitting or injuring the client.

A: ECG results. This is not a finding that suggests elder abuse or neglect. It is a diagnostic test that measures the electrical activity of the heart and can help detect cardiac problems. It does not provide information about the client’s social or emotional well-being.

Normal ranges for vital signs:.

Temperature: 36.1°C to 37.2°C (97°F to 99°F).
Heart rate: 60 to 100 beats per minute.
Blood pressure: less than 120/80 mm Hg.
Respiratory rate: 12 to 20 breaths per minute.
SpO2: 95% to 100% on room air. Table for BMI categories:

BMI	Weight Status
Below 18.5	Underweight
18.5 to 24.9	Normal
25.0 to 29.9	Overweight
30.0 and above	Obese

The client’s BMI is 18.3, which indicates he is underweight and may be malnourished or have a medical condition that causes weight loss.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

The correct answer is choice C. Taking a hot shower in the morning can help decrease stiffness and improve joint mobility for people with rheumatoid arthritis. This is one of the self-management strategies that can reduce pain and disability.

Choice A is wrong because applying cold packs directly on the skin of the affected joints can cause vasoconstriction and increase inflammation.

Cold therapy should be used with caution and with a barrier between the skin and the ice pack.

Choice B is wrong because biological response modifiers are not used to prevent infection, but to reduce inflammation and slow down joint damage in rheumatoid arthritis.

These medications can actually increase the risk of infection by suppressing the immune system.

Choice D is wrong because clustering physical activities during the day can cause fatigue and joint stress for people with rheumatoid arthritis.

It is better to pace activities throughout the day and take frequent breaks to rest the joints.

Normal ranges for rheumatoid arthritis are based on the disease activity score (DAS), which measures the number of swollen and tender joints, the level of inflammation in the blood, and the patient’s global assessment of health. A DAS below 2.6 indicates remission, a DAS between 2.6 and 3.2 indicates low disease activity, a DAS between 3.2 and 5.1 indicates moderate disease activity, and a DAS above 5.1 indicates high disease activity.

A. Infuse the medication over 10 min. B. Instruct the client to notify the provider if diarrhea develops. C. Refrigerate the medication after reconstitution. D. Check the client for a sulfa allergy.

Correct Answer is B

Explanation

The correct answer is choiceb. Instruct the client to notify the provider if diarrhea develops.

Choice A rationale:

Infusing penicillin G over 10 minutes is not recommended as it may cause adverse reactions.The infusion rate should be based on the specific guidelines for the medication and patient condition.

Choice B rationale:

Diarrhea can be a sign of a serious side effect called Clostridium difficile-associated diarrhea, which can occur with antibiotic use.It is important for the client to notify the provider if this symptom develops.

Choice C rationale:

Penicillin G should be stored according to the manufacturer’s instructions, which typically do not include refrigeration after reconstitution.Incorrect storage can affect the medication’s efficacy.

Choice D rationale:

Checking for a sulfa allergy is not relevant for penicillin G administration.Sulfa allergies are related to sulfonamide antibiotics, not penicillins.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has rheumatoid arthritis about illness management. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is caring for a client who is receiving penicillin G via intermittent IV piggyback. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis following a stroke. Which of the following actions by the nurse best promotes communication among staff caring for the client?

A nurse is making an initial postpartum home visit. Which of the following client statements should the nurse identify as a manifestation of increased risk for child abuse?

A nurse is reporting a client’s laboratory tests to the provider to obtain a prescription for the client’s daily warfarin. Which of the following laboratory tests should the nurse plan to report to obtain the prescription for the warfarin?

A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse identify as tertiary prevention?

A nurse is admitting a client who is hesitant to create advance directives due to concerns about affording legal representation. Which of the following statements should the nurse make?

A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report?

A nurse is caring for a client who is admitted to the medical-surgical unit. Client reports, "I'm bloated and my stomach hurts." Exhibits The nurse reviews the client's laboratory findings and vital signs. Select the 5 findings that require immediate follow-up.

A nurse is assisting with food selection for a client who follows kosher dietary traditions. Which of the following food choices should the nurse include on the client’s food tray?