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A nurse is caring for an older adult client

Adult child accompanying parent reports cognitive and physical decline in the client, expressing concern over memory loss, thought processes, appetite, and self-care. Adult child states, "My sibling and I hired help at home for my parent. We thought that might 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 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

1030:.

Client found sitting in waiting room, head in hands. Client says, "Why don't you just leave me? I am of no use.”

Vital Signs 0945:.

Temperature 37.7° C (99.9° F) Heart rate 68/min

Respiratory rate 16/min BP 136/80 mm Hg

Oxygen saturation 100% on room air

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.

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Correct Answer is D

Explanation

A firewall is a system that protects the network from unauthorized access and prevents data breaches. A firewall is essential for ensuring the confidentiality, integrity, and availability of electronic health records.
Choice A is wrong because the nurse should change their password more frequently than once per year. Changing passwords regularly reduces the risk of unauthorized access and enhances security.
Choice B is wrong because the documentation of sensitive material is not performed by the charge nurse. The nurse who provides the care should document it accurately and promptly in the computerized system.
Choice C is wrong because the nurse will not be given access to the medical records of every client in the facility. The nurse should only access the records of the clients they are assigned to care for, following the principle of need-to-know.

A. Encourage collaboration between the two nurses when making the assignments. B. Tell the nurses that the assignments will be more equitable in the future. C. Ask each nurse to take turns making the assignments. D. Arrange for the nurses to have as few shifts together as possible.

Correct Answer is A

Explanation

This is because collaboration is one of the most effective conflict-resolution strategies in nursing, as it involves finding a mutually beneficial solution that satisfies both parties and improves the quality of care. Collaboration can also foster trust, respect, and teamwork among nurses, which can boost morale and efficiency.

Choice B is wrong because telling the nurses that the assignments will be more equitable in the future does not address the root cause of the conflict or involve the nurses in the decision-making process.
It also implies that the charge nurse admits to being unfair, which can damage their credibility and authority.
Choice C is wrong because asking each nurse to take turns making the assignments does not resolve the conflict, but rather avoids it. Avoidance is one of the least effective conflict management strategies in nursing, as it results in not addressing the issue or finding common ground.
Avoidance can also lead to resentment, frustration, and poor communication among nurses.
Choice D is wrong because arranging for the nurses to have as few shifts together as possible also does not resolve the conflict, but rather accommodates it. Accommodation is another ineffective conflict management strategy in nursing, as it involves giving in to one party’s demands or preferences at the expense of another’s.
Accommodation can also create a sense of inequality, injustice, and dissatisfaction among nurses.
Normal ranges for conflict-resolution strategies in nursing are not applicable, as different situations may require different approaches. However, some general guidelines are to use collaboration when both parties have important goals or interests, compromise when both parties have some common ground or willingness to give up something, competition when one party has a clear advantage or authority, avoidance when the conflict is trivial or temporary, and accommodation when one party values harmony or relationships more than their own goals or interests.

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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 charge nurse is teaching a newly licensed nurse about the facility’s computerized documentation system. Which of the following information should the nurse include?

Correct Answer is D

Explanation

A charge nurse is observing a conflict between two nurses who both insist that the charge nurse favors the other when making assignments. Which of the following conflict-resolution strategies should the charge nurse use?

Correct Answer is A

Explanation

A nurse is administering furosemide IV bolus to a client who has fluid volume excess. The nurse should recognize which of the following findings is an indication that the medication has been effective

A nurse is caring for a client who is immobile. Which of the following interventions is appropriate to prevent contracture?

A nurse is preparing to administer a medication that is available in a glass ampule. Which of the following actions should the nurse plan to take?

A nurse is preparing to administer vancomycin IV to an adult client. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse make?

A public health nurse working in a rural area is developing a program to improve health for the local population. Which of the following actions should the nurse plan to take?

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following findings indicates that the child may be experiencing hemorrhage?

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

A nurse is preparing to insert an IV catheter for a client. Which of the following actions should the nurse plan to take?