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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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Free Nursing Study Resources

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

Explanation

The correct answers are B and C.

Choice A Reason: Transferring a client who is receiving radiation therapy involves understanding the precautions and care associated with radiation, which may be beyond the training of assistive personnel (AP). Radiation therapy clients may have specific safety and transport protocols that require the expertise of licensed nursing staff.

Choice B Reason: Measuring vital signs for a client who requires contact precautions is a task that can be delegated to AP. Assistive personnel can be trained in infection control procedures and the use of personal protective equipment (PPE), making them capable of measuring vital signs while adhering to contact precautions.

Choice C Reason: Recording urine output for a client who has a suprapubic catheter can be delegated to AP. This task involves measuring and documenting a quantifiable data point, which does not require the clinical judgment of a nurse. AP can be trained to accurately measure and record urine output.

Choice D Reason: Planning care for a client who has dysphagia is a complex task that involves assessment and clinical judgment, which are responsibilities of the licensed nurse. Dysphagia can have serious complications, and care plans must be tailored to each client’s needs, requiring the expertise of a nurse.

A. Euphoria B. Bradypnea C. Constipation D. Constipation

Correct Answer is B

Explanation

The correct answer is choice B, bradypnea. Bradypnea is abnormally slow breathing, which can be a sign of life-threatening respiratory depression caused by morphine. Respiratory depression is the most serious adverse effect of morphine and can lead to coma and death if not treated promptly. Therefore, the nurse should monitor the child’s respiratory rate and oxygen saturation closely and be prepared to administer naloxone, an opioid antagonist, if needed.

Choice A, euphoria, is wrong because euphoria is a feeling of intense happiness or well-being that is a common side effect of morphine.

Euphoria is not a priority finding and does not indicate a serious complication of morphine.

Choice C, constipation, is wrong because constipation is a common and chronic side effect of morphine that affects the gastrointestinal system.

Constipation can cause discomfort and complications such as bowel obstruction, but it is not a priority finding compared to respiratory depression.

Choice D, sedation, is wrong because sedation is another common side effect of morphine that affects the central nervous system.

Sedation can impair the child’s level of consciousness and ability to respond to stimuli, but it is not as urgent as respiratory depression.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is delegating care for a group of clients for the oncoming shift. Which of the following tasks should the nurse delegate to an assistive personnel? (select all that apply)

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

Explanation

A nurse is caring for a school-age child who is postoperative and received morphine via IV bolus for pain 10 min ago. Which of the following findings is the nurse’s priority?

Correct Answer is B

Explanation

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