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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.

Answer and Explanation

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.

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Correct Answer is ["C","E","F"]

Explanation

c. Report suspected maltreatment to the appropriate agency.

e. Ask the client how the fracture occurred.

f. Conduct the interview with the client privately.

In a situation where maltreatment is suspected, it is important for the nurse to report their concerns to the appropriate agency. The nurse should also ask the client how the fracture occurred and conduct the interview with the client privately, without the presence of their child, to gather more information and assess the situation.

A. Grandiose thinking B. Hypersomnia C. Blunted affect D. Slurred speech

Correct Answer is A

Explanation

Clients in the manic phase often exhibit inflated self-esteem, a sense of superiority, and grandiose thinking. They may have unrealistic beliefs about their abilities, accomplishments, or importance.

Hypersomnia, or excessive sleepiness, is not typically associated with the manic phase of bipolar disorder. Instead, individuals in the manic phase often experience a decreased need for sleep and may go for long periods with little or no sleep.

Blunted affect refers to a lack of emotional expression or reduced intensity of emotional responses. It is more commonly associated with depressive episodes of bipolar disorder rather than the manic phase.

Slurred speech is not a typical finding in the manic phase of bipolar disorder. However, individuals in the manic phase may exhibit rapid or pressured speech, talking excessively, rapidly switching topics, or having difficulty keeping up with their own thoughts.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is identifying tertiary prevention strategies to implement for this client. Exhibits Select the three actions the nurse should take.

Correct Answer is ["C","E","F"]

Explanation

A nurse is collecting data from a client who is in the manic phase of bipolar disorder. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is collecting data from a client who is at 20 weeks of gestation and has been taking ferrous sulfate. For which of the following findings should the nurse monitor as a common adverse effect of iron supplementation and report to the provider?

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