A nurse is caring for a newly admited older adult client.
Nurses' Notes
Day 1, 12:00:
Transferred to medical-surgical unit from emergency department (ED) for continued care following a closed reduction and immobilization of a fracture of the right arm. Accompanied by adult child.
Client in visibly soiled night clothes with multiple stains, including what appears to be dried blood. Hair, teeth, and fingernails unclean. Strong body odor noted. Bruising of various stages noted around upper arms, back, shoulders, and neck area.
Client is soft-spoken, speaks almost in a whisper, does not make eye contact with nurse.
Client looks at their child before answering the nurse's questions and, when asked how the injury occurred, mumbles "I don't know. Ask them." Client's child states, "He gets confused sometimes. I can answer your questions."
Which of the following interventions should the nurse recommend to include in the client's plan of care?
Select all that apply.
Tell the client's child that they will be reported for maltreatment of the client.
Ask the client's child to provide details regarding the client's fractured arm.
Discuss respite care options with the client's child.
Speak to the client privately.
Provide legal advice to the client regarding power of atorney.
Correct Answer : B,C,D
The correct answers are b, c, and d.
a. It is not appropriate for the nurse to threaten the client's child with reporting for maltreatment without
further assessment and evidence.
b. Asking the client's child to provide details regarding the client's fractured arm will provide additional information about the client's injury and help the nurse assess the potential for abuse or neglect.
c. Discussing respite care options with the client's child may help alleviate any caregiver stress or burden, and ensure the client's continued care and safety.
d. Speaking to the client privately will help establish trust and rapport, and allow the client to disclose any concerns or issues that they may not feel comfortable sharing in front of their child.
e. Providing legal advice regarding power of atorney is not within the scope of nursing practice and should be referred to a legal professional. Additionally, the client's capacity to make decisions and appoint a power of atorney should be assessed before providing such advice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
A client who has a spinal cord injury is correct. An interprofessional conference is often recommended for clients with complex and multifaceted health issues that require collaboration among various healthcare disciplines. A client with a spinal cord injury typically has complex care needs that involve multiple healthcare professionals, such as physical therapists, occupational therapists, social workers, nurses, and possibly surgeons or neurologists. The coordination of care for a client with a spinal cord injury often requires input and collaboration from various healthcare team members, making an interprofessional conference valuable.
Choice B Reason:
A torn rotator cuff may require physical therapy and orthopedic consultation but may not require the same level of multidisciplinary collaboration as a spinal cord injury.
Choice C Reason:
Acute appendicitis typically involves surgical intervention but may not require the same degree of ongoing interprofessional collaboration as other complex conditions.
Choice D Reason:
A urinary tract infection is a common and relatively straightforward condition that is usually managed by nurses and primary care providers without extensive interprofessional conferences.
Correct Answer is B
Explanation
Choice A Reason:
Decreased BUN (blood urea nitrogen) level is incorrect. While furosemide can lead to decreased BUN levels, it is not the primary indicator of its effectiveness. BUN levels can be influenced by various factors, including hydration status and kidney function.
Choice B Reason:
Increased urinary output is correct. Furosemide is a diuretic medication often prescribed to clients with heart failure to help manage fluid retention. One of the primary therapeutic effects of furosemide is increased urinary output, which indicates that the medication is effectively removing excess fluid from the body.
Choice C Reason:
Decreased hemoglobin level is incorrect. Furosemide is not directly associated with changes in hemoglobin levels. Hemoglobin levels reflect the oxygen-carrying capacity of the blood and are typically not affected by diuretic therapy.
Choice D Reason:
Increased weight of 0.91 kg (2 lb.) is incorrect. An increase in weight is not indicative of the medication's effectiveness. In fact, weight gain could be a sign of fluid retention and heart failure exacerbation, which would suggest that the medication may not be working optimally.
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