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 C
Explanation
c. New onset of hearing loss.
When collecting data from a client who is receiving gentamicin via IV infusion, the nurse should identify new onset of hearing loss as an adverse effect of the treatment¹. Gentamicin can cause vestibulocochlear nerve damage, which can affect hearing and balance¹.
Correct Answer is C
Explanation
Iron supplementation commonly causes constipation, which is due to the iron's effect of slowing down bowel movements and increasing water absorption in the intestines.
Dry mouth is not a common adverse effect of iron supplementation. It is more commonly associated with medications that can cause xerostomia (dry mouth), such as certain antihistamines or anticholinergic drugs.
Tinnitus, a perception of ringing or noise in the ears, is not typically associated with iron supplementation. Tinnitus can be caused by various factors, such as exposure to loud noises, ear infections, or certain medications, but it is not directly related to iron supplementation.
Hematuria, the presence of blood in the urine, is not a common adverse effect of iron supplementation. It can be caused by various conditions affecting the urinary system, such as urinary tract infections, kidney stones, or bladder issues, but it is not directly related to iron supplementation.
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