A nurse is caring for a newly admitted older adult client.

Nurses' Notes

Day 1, 12:00:

Transferred to the medical-surgical unit from the emergency department (ED) for continued care following a closed reduction and immobilization of a fracture of the right arm. Accompanied by an 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.

The client is soft-spoken, speaks almost in a whisper, and does not make eye contact with the nurse.

The 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." The 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 the power of attorney.

Answer and Explanation

Correct Answer : B,C,D

It is not appropriate for the nurse to threaten the client's child with reporting for maltreatment without further assessment and evidence.

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.

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.

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.

Providing legal advice regarding power of attorney 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 attorney should be assessed before providing such advice.

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Correct Answer is C

Explanation

A.While monitoring the client's physical condition, including range of motion, is important, it typically needs to be done more frequently than every 60 minutes. The Joint Commission and other regulatory bodies often recommend continuous observation and checks every 15 minutes.

B.Typically, a provider's order for restraints must be obtained immediately or within a very short time frame (often within an hour), not 48 hours. Regulations vary but generally require prompt notification and authorization.

C.Restraints should only be used as a last resort and for the shortest duration possible. The goal is to ensure the client's safety and the safety of others while minimizing the use of restraints. Removing the restraints as soon as the client is calm and no longer a threat to themselves or others is essential to respecting the client's rights and promoting their dignity.

D.Offer the client a nutritious snack every 4 hr.: While providing nutrition and hydration is important, the primary focus immediately after applying restraints should be on the client's safety and the frequent assessment of their condition. Offering a snack every 4 hours is not the immediate priority in this context.

A. Ecchymosis on the inner left thigh B. One fingerbreadth of space between the cast and the skin C. Diminished pulses on the aﬀected extremity D. Client report of muscle spasms of the left leg

Correct Answer is C

Explanation

Diminished pulses on the aﬀected extremity. This finding may indicate compromised circulation, which is
a serious complication that requires immediate intervention.
Option a. Ecchymosis on the inner left thigh may be a concerning finding, but it is not as urgent as diminished pulses. Ecchymosis may be a result of trauma during cast application and may resolve on its own.
Option b. One fingerbreadth of space between the cast and the skin is a normal finding and indicates that the cast is not too tight.
Option d. Client report of muscle spasms of the left leg is a common complaint in clients with casts and may
be addressed with medication or other interventions, but it is not as urgent as diminished pulses.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an acute mental-health facility is caring for an adolescent who is exhibiting destructive behavior. Which of the following actions should the nurse take after applying physical restraints to the client?

Correct Answer is C

Explanation

A nurse is collecting data from a client who has a long leg cast on his left leg. Which of the following findings is the priority?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client who has a new prescription for atorvastatin. For which of the following adverse eﬀects should the nurse instruct the client to monitor and report to the provider?

A nurse is participating in an interprofessional team meeting for a client. Which of the following information about the client should the nurse include?

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 reinforcing teaching about common discomforts during the first trimester with a client who is at 10 weeks of gestation. Which of the following examples should the nurse include?

A nurse is reinforcing teaching with a client who has a urinary tract infection. Which of the following instructions should the nurse include in the teaching?

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?

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?

A nurse is supervising an assistive personnel (AP) who is providing client care. The nurse should identify that which of the following actions by the AP demonstrates effective use of supplies?