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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.

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Correct Answer is D

Explanation

Choice A reason:

Determine previous coping skills used by the client is not appropriate. Assessing the client's previous coping skills is an essential step in the assessment phase of the therapeutic relationship, not specifically during the orientation phase. This information helps the nurse to understand the client's coping mechanisms and identify potential areas for improvement or support.

Choice B reason:

Facilitate the client's problem-solving skills is not appropriate the nurse may work on facilitating the client's problem-solving skills throughout the therapeutic relationship, including during the working phase. During this phase, the nurse and client collaborate to explore and address the client's concerns and challenges.

Choice Creason:

Assisting the client in expressing alternative behaviours is not appropriate. This action may also be part of the working phase, where the nurse helps the client explore alternative behaviours and coping strategies to address their issues and challenges.

Choice D reason:

The orientation phase is the initial stage of the therapeutic relationship where the nurse and the client get to know each other and establish the groundwork for their working relationship. During this phase, it is essential to clarify the roles and responsibilities of both the nurse and the client to ensure a clear understanding of each other's expectations.

A. Review the need for the indwelling urinary catheter daily. B. Place the drainage bag on the bed when transporting the client. C. Use soap and water to provide perineal care. D. Encourage the client to drink 3000 mL of fluid daily. E. Change the indwelling urinary catheter tubing every 3 days. F. Empty the drainage bag when it is half-full.

Correct Answer is ["A","C"]

Explanation

A: Review the need for the indwelling urinary catheter daily.
This is correct because indwelling catheters should be removed as soon as possible to reduce the risk of urinary tract infection (UTI).

B: Place the drainage bag on the bed when transporting the client.
This is incorrect because the drainage bag should be kept below the level of the bladder and should not touch the floor to prevent the backflow of urine and contamination of the catheter.

C: Use soap and water to provide perineal care.
This is correct because soap and water can help to remove bacteria and debris from the meatus and prevent infection.

D: Encourage the client to drink 3000 mL of fluid daily.
This is incorrect because the client has a fluid restriction of 1000 mL daily due to heart failure. Excessive fluid intake can worsen the client’s condition and increase the workload of the heart.

E: Change the indwelling urinary catheter tubing every 3 days.
This is incorrect because changing the catheter tubing can increase the risk of infection by breaking the closed drainage system. The catheter tubing should only be changed when it is visibly soiled or malfunctioning.

F: Empty the drainage bag when it is half full.
This is incorrect because the drainage bag should be emptied at least every 8 hours or when it is one-third full to prevent back pressure and infection.

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Naxlex Comprehensive Predictor Exams

A nurse is building a therapeutic relationship with a newly admitted client. Which of the following actions should the nurse plan to take during the orientation phase of the relationship?

Correct Answer is D

Explanation

A nurse is caring for a client in the medical-surgical unit. Exhibits Which of the following actions should the nurse take to decrease the risks for urinary tract infection for this client? Select all that apply.

Correct Answer is ["A","C"]

Explanation

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