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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

a. Location of the identification tag on the client's body: This is essential information that should be included in the documentation. It ensures that the deceased person is properly identified and helps prevent any mix-ups during subsequent processes, such as transferring the body to the morgue or a funeral home.

b-While this information is important, it's typically documented by the physician on the death certificate and is not generally part of the nurse's postmortem documentation.

c-The last set of vital signs is not usually required for postmortem documentation. Postmortem documentation focuses on the condition of the body and identification rather than the final vital signs, which are often irrelevant after death.

d-Advance directives should be reviewed before death and guide the care provided, but they are not part of postmortem documentation. A copy of the client's advance directives may also be included in their medical record but is not typically included in postmortem documentation.

A. Loss of taste B. Loose stools C. increased appetite D. Bladder infection

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

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is A

Explanation

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 is caring for a client who has a prescription for warfarin. Which of the following laboratory tests should the nurse monitor?

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 caring for a client who recently gave birth to her first child. The newborn is crying and the client states, "I can't seem to do anything right. What should I do?" Which of the following responses should the nurse make?

A nurse is assisting with the plan of care for a client who has burns to his lower extremities. Which of the following actions should the nurse include in the plan?

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 reinforcing discharge teaching with the caregiver of a client who has dependent personality disorder. Which of the following instructions should the nurse include in the teaching?

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 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?