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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 ["B","C"]

Explanation

Turn cellular phones to silent mode: In an active shooter situation, it is crucial to maintain silence to avoid drawing attention to your location. Switching cellular phones to silent mode helps ensure that ringtones or notifications do not alert the shooter to your presence.

Wave hands to attract the attention of law enforcement: When law enforcement or emergency personnel arrive at the scene, it is essential to signal to them that you are not a threat and that you require assistance. This can be done by putting hands up, keeping them visible, and following any instructions provided by law enforcement.

Move wounded clients to a safe area before finding shelter: It is important to prioritize the safety of individuals involved in an active shooter situation. However, moving wounded clients should be done only if it can be done quickly and without putting oneself or others at risk. The primary goal is to seek safety and follow established protocols, such as "run, hide, fight" principles, rather than focusing on moving injured individuals during an ongoing threat.

Attempt to bargain with the shooter: Bargaining or negotiating with an active shooter is strongly discouraged. It is important to remember that the primary goal in an active shooter situation is to ensure personal safety and the safety of others. Engaging with the shooter may escalate the situation or put oneself and others at greater risk.

The in-service should focus on providing staff members with practical guidance on how to respond to an active shooter situation, emphasizing the importance of following established protocols, staying calm, and seeking safety. Additionally, the in-service should include training on recognizing and reporting suspicious behavior, as prevention and early intervention can play a crucial role in mitigating such incidents.

A. "Restrict your daily fluid intake while taking this medication." B. "Expect to experience diarrhea while taking this medication." C. "This medication can increase your risk for sunburn." D. "Take an antacid if the medication causes gastrointestinal upset."

Correct Answer is C

Explanation

a.Adequate fluid intake is important while taking ciprofloxacin to prevent dehydration, especially if diarrhea occurs.

b. Ciprofloxacin can disrupt the normal balance of bacteria in the gastrointestinal tract, potentially leading to diarrhea. Informing the client about this possible side effect allows them to be prepared and take appropriate measures, such as maintaining hydration and notifying their healthcare provider if diarrhea becomes severe or persistent. However, warning about sunburnis crucial as it addresses a specific side effect (photosensitivity) that clients may not be aware of, and it provides actionable advice to mitigate the risk (use of sunscreen and protective clothing).

c.Ciprofloxacin, like other fluoroquinolone antibiotics, can increase sensitivity to sunlight (photosensitivity). Clients should be advised to use sunscreen, wear protective clothing, and avoid prolonged sun exposure while taking this medication.

d.Ciprofloxacin should not be taken with antacids, calcium supplements, or dairy products because they can interfere with the absorption of the medication. It's best to take ciprofloxacin either 2 hours before or 6 hours after taking antacids or products containing calcium, magnesium, aluminum, iron, or zinc.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with planning an in-service for staff members about active shooter protocols. Which of the following information should the nurse recommend including?

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

Explanation

A nurse is reinforcing teaching with a client who has a new prescription for ciprofloxacin. Which of the following information should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client who has diabetes mellitus about a 24-hour creatinine clearance test. Which of the following statements should the nurse include in the teaching?

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse plan to take?

A nurse is collecting data from a client who has heart failure and is taking furosemide. Which of the following findings should indicate to the nurse that the medication is eﬀective?

A nurse in a mental health facility is caring for a client who reports palpitations and a sense of impending doom. Which of the following actions should the nurse take first?

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

A community health nurse is assisting with the development of a pamphlet regarding choking hazards for toddlers. Which of the following foods should the nurse include?

A nurse is performing nasopharyngeal suctioning for an adult client. Which of the following techniques should the nurse use?

A nurse is caring for a client who speaks a different language than the nurse. The client's partner tells the nurse that the client would like to go home against medical advice (AMA). Which of the following actions should the nurse take?