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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Free Nursing Study Resources

Correct Answer is C

Explanation

Iron supplementation commonly causes constipation, which is due to the iron's effect of slowing down bowel movements and increasing water absorption in the intestines.

Dry mouth is not a common adverse effect of iron supplementation. It is more commonly associated with medications that can cause xerostomia (dry mouth), such as certain antihistamines or anticholinergic drugs.

Tinnitus, a perception of ringing or noise in the ears, is not typically associated with iron supplementation. Tinnitus can be caused by various factors, such as exposure to loud noises, ear infections, or certain medications, but it is not directly related to iron supplementation.

Hematuria, the presence of blood in the urine, is not a common adverse effect of iron supplementation. It can be caused by various conditions affecting the urinary system, such as urinary tract infections, kidney stones, or bladder issues, but it is not directly related to iron supplementation.

A. Report the incident to the charge nurse. B. Participate in an in-service about client confidentiality. C. Tell the staff members to stop their discussion. D. Speak to the staff members in private about client confidentiality.

Correct Answer is C

Explanation

a.While reporting the incident is important, the priority is to stop the confidentiality breach immediately to protect the client's privacy.

b.Participating in training is important for long-term education, but it does not address the immediate issue of the confidentiality breach.

c. Tell the staff members to stop their discussion: This action stops the breach immediately and protects the client's confidential information, which is the first and most crucial step.

d.Speak to the staff members in private about client confidentiality: While this is a good follow-up action to educate and prevent future breaches, the immediate need is to stop the ongoing discussion

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

A nurse overhears two assistive personnel discussing a client's medical history in the hallway. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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 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 anorexia nervosa and a behavioral management plan in place. Which of the following findings should the nurse identify as an indication that the behavioral plan is effective?

A nurse overhears two assistive personnel (AP) in the nurses' station discussing a client who was recently admitted. Which of the following actions should the nurse take?

A nurse is administering pancrelipase to a child who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment?

A nurse is assisting with the admission of an adolescent client who is suspected to have bacterial meningitis. Which of the following findings should the nurse expect?

A nurse is reinforcing teaching with a client who is about to start using an albuterol metered-dose inhaler. Which of the following instructions should the nurse include in the teaching?

A nurse is collecting data from a client who is taking tranylcypromine and reports ingestion of tyramine-rich foods. The nurse should monitor the client for which of the following findings as an adverse effect of this medication?