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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Radiation therapy can affect the taste buds, leading to a diminished or altered sense of taste.

This can result in a reduced appetite or changes in food preferences.

Loose stools and bladder infection are not commonly associated with external radiation for throat cancer. Loose stools can be a side effect of radiation therapy to the abdomen or pelvis, but it is not typically seen in throat cancer treatment.

Bladder infection is not directly related to radiation therapy, but it can occur as a complication in some individuals undergoing cancer treatment, especially if they have a compromised immune system.

Increased appetite is also not a typical finding associated with radiation therapy, as it may cause side effects such as nausea or changes in taste, which can decrease appetite

A. Family medical history B. Medications taken prior to admission C. Physical assessment findings D. Medical health insurance claims

Correct Answer is C

Explanation

c. Physical assessment findings

Physical assessment findings are important to include in a referral for a physical therapist because they provide information about the client's current physical condition, including range of motion, strength, and any areas of pain or discomfort.

This information is essential for the physical therapist to develop an appropriate treatment plan for the client. Family medical history and medical health insurance claims may be important for overall client care, but are not directly relevant to a referral for a physical therapist.

Medications taken prior to admission may be relevant if they aﬀect the client's physical abilities or pain level, but again, physical assessment findings are more directly related to the referral for a physical therapist.

View Question and Answer

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who has received external radiation for throat cancer. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse in an acute care setting is assisting in collecting client information to include in a referral for a physical therapist. Which of the following information should the nurse plan to include?

Correct Answer is C

Explanation

A nurse is caring for a client who has peptic ulcer disease and is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take prior to the procedure?

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

A nurse is assisting with a community health program for caregivers of clients who have Alzheimer's disease. Which of the following information should the nurse include?

A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hr PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this client care incident?

A nurse is completing postmortem documentation for a client. Which of the following information should the nurse include in the documentation?

A nurse is providing change-of-shift report for a client. Which of the following information should the nurse include in the report?

A nurse is caring for a client who has end-stage kidney disease. The client has decided to stop dialysis treatment. Which of the following actions should the nurse take?

A nurse is reviewing the medical record of a client who has COPD. Which of the following laboratory findings indicates a need to request a dietary referral for the client?