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A nurse is caring for an older adult client.

exhibits

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.

System

Findings

General

Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states. "My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me."

Physical

Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom." Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min

Affect

Client says. "Why don't you just leave me? I am of no use.”

My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me.

Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression.

you just leave me? I am of no use.

Client reports not wanting to eat anymore

child reports their parent has lost about 8 lb in the past month

Answer and Explanation

The Correct Answer is ["A","B","C","D","E"]

The findings that require immediate follow-up are:.

- Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states. “My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me.”.
- Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports not wanting to eat anymore. Client’s child reports their parent has lost about 8 lb in the past month.
- Client says. "Why don’t you just leave me? I am of no use.”.

These findings suggest that the client may have cognitive impairment, depression, and/or malnutrition, which can affect their health and quality of life. The nurse should perform a comprehensive assessment of the client’s cognitive, behavioral, and functional status, review their medications and possible side effects, provide education and support for healthy aging, and collaborate with interdisciplinary teams and community resources. The nurse should also evaluate the client’s home environment and lifestyle, and consider nonpharmacological approaches to manage behavioral problems. The nurse should also monitor the client’s vital signs and weight regularly.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is D

Explanation

This is because placing a wedge under one of the hips can help prevent compression of the inferior vena cava by the uterus, which can compromise placental blood flow and cause fetal hypoxia. Placing a wedge under the hip can also help reduce the risk of maternal hypotension, which can also affect fetal oxygenation.
Choice A is wrong because inserting a pillow under the client’s knees can increase the risk of thromboembolism, which is a potential complication of cesarean birth.
Choice B is wrong because positioning the client in reverse Trendelenburg can increase the risk of maternal aspiration, which is another potential complication of cesarean birth.
Choice C is wrong because assisting the client into the lithotomy position can also compress the inferior vena cava and reduce placental blood flow. The lithotomy position is also not necessary for cesarean birth, as the baby is delivered through an incision in the abdomen and uterus.

A. Replace the NG tube. B. Provide oral hygiene care. C. Administer an antiemetic medication. D. Evaluate functioning of the suction device.

Correct Answer is D

Explanation

This is because the first priority for the nurse is to assess the cause of the vomiting and ensure that the NG tube is working properly. If the suction device is malfunctioning, it could lead to gastric distension, nausea and vomiting. The nurse should check the suction settings, tubing, canister and connections for any problems.

Choice A is wrong because replacing the NG tube is not the first action to take.

The nurse should first rule out other causes of vomiting before attempting to reinsert the tube, which could be uncomfortable and risky for the client.

Choice B is wrong because providing oral hygiene care is not the most urgent action to take.

While oral hygiene care is important for comfort and infection prevention, it does not address the underlying cause of vomiting or prevent further complications.

Choice C is wrong because administering an antiemetic medication is not the most appropriate action to take.

The nurse should first identify the cause of vomiting and correct it if possible.

Giving an antiemetic medication without resolving the problem could mask symptoms and delay treatment.

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System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states. "My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me."
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom." Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says. "Why don't you just leave me? I am of no use.”

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is positioning a client for a cesarean birth. To prevent a compromise in placental blood flow during the intraoperative period, which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited. Which of the following actions should the nurse perform first?

Correct Answer is D

Explanation

A nurse is providing discharge teaching to a client who is postoperative following surgery for carpal tunnel syndrome. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is planning to teach a client about taking prednisone. Which of the following instructions should the nurse include?

A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following actions should the nurse plan to take?

A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?

A nurse in an emergency department is reviewing the medical record of a client who is having an acute myocardial infarction. Which of the following findings places the client at risk if he receives alteplase?

A nurse inadvertently administers 160 mg of valsartan PO to a client who was scheduled to receive 80 mg. Which of the following actions is the priority for the nurse to take?

While performing a routine assessment, a nurse notices fraying on the electrical cord of a client’s continuous passive motion (CPM) device. Which of the following actions should the nurse take first?

A nurse is reviewing a client’s cardiac rhythm strips and notes a constant P-R interval of 0.35 seconds. Which of the following dysrhythmias is the client displaying?