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 D
Explanation
Choice A Reason:
Chloasma is incorrect. Chloasma, also known as the "mask of pregnancy," refers to the brownish or tan patches of pigmentation that can appear on the face during pregnancy. It is not related to the purplish discoloration of the cervix, vagina, and vulva described in the scenario.
Choice B Reason:
Hegar's sign is incorrect. Hegar's sign is a softening and compressibility of the lower uterine segment (the area between the cervix and the body of the uterus) that can be felt during a pelvic examination. It is not related to discoloration of the genital area.
Choice C Reason:
Ballottement is incorrect. Ballottement is a technique used during a pelvic examination to assess the fetus's position and is characterized by the examiner feeling a rebound movement of the fetus when it is pushed and then released. It does not involve discoloration of the genital area.
Choice D Reason:
Chadwick's sign is a bluish-purple or purplish discoloration of the cervix, vagina, and vulva that can occur during pregnancy. This discoloration is due to increased blood flow to the pelvic area and is considered a normal physiological change during pregnancy. It is one of the early signs of pregnancy and can be observed as early as the sixth week of gestation. It is named after the American obstetrician James Read Chadwick, who first described it.
Correct Answer is D
Explanation
Choice A Reason:
Explaining the procedure's purpose is incorrect. While explaining the procedure's purpose is essential, it should not be done as a sole response if the client has expressed a lack of understanding. The client's concerns and questions need to be addressed first.
Choice B Reason:
Reminding the client about the specifics of the procedure is incorrect. This choice assumes that the client is aware of the specifics but has forgotten them. If the client has already stated that they don't understand why the procedure is necessary, simply reminding them of the details may not address their concerns adequately.
Choice C is Reason:
Asking the client to sign the consent form anyway is incorrect. This option is not appropriate because it would violate the principle of informed consent. Informed consent requires that the client fully understands the procedure, its purpose, potential risks, and alternatives before signing the form. If the client doesn't understand, signing the form would not be informed consent.
Choice D Reason:
Notifying the charge nurse about the situation is correct. When a client expresses a lack of understanding or confusion about a medical procedure, it is essential to ensure that the client fully comprehends the procedure, its purpose, potential risks, and alternatives. The nurse should not proceed with obtaining informed consent if the client does not understand. Instead, the charge nurse or another healthcare provider should be notified to address the client's concerns and provide further clarification. It's crucial to prioritize the client's right to make an informed decision regarding their healthcare.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.