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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 C

Explanation

This is because a normal FHR baseline is between 110 and 160 bpm, and anything above or below this range indicates fetal distress and should be reported to the provider. An FHR baseline of 170/min could indicate fetal tachycardia, which could be caused by maternal fever, infection, dehydration, fetal anemia, or fetal hypoxia.
Choice A is wrong because early decelerations in the FHR are normal and benign, and indicate head compression during contractions.
They do not require any intervention or reporting.
Choice B is wrong because contractions lasting 80 seconds are within the normal range for active labor, which is 40 to 90 seconds per contraction.
They do not indicate any complication or abnormality.
Choice D is wrong because a temperature of 37.4° C (99.3° F) is slightly elevated but not considered a fever. A fever is defined as a temperature of 38° C (100.4° F) or higher.
A mild increase in temperature could be due to dehydration, exertion, or environmental factors, and does not necessarily indicate infection or inflammation.

A. Unclamp the collection port below the bag. B. Obtain the specimen from the retention port. C. Disconnect the catheter from the collection tubing. D. Use the balloon port to obtain the sterile specimen.

Correct Answer is B

Explanation

This is because the retention port is a sterile site that can be accessed by a syringe to aspirate urine without contaminating the specimen or the closed drainage system. The retention port should be cleaned with an alcohol swab before inserting the syringe. The specimen should be transferred to a sterile container and labeled appropriately.
Choice A is wrong because unclamping the collection port below the bag would allow urine to flow out of the bag, which is not sterile and may contain bacteria or sediment.
Choice C is wrong because disconnecting the catheter from the collection tubing would break the closed drainage system and increase the risk of infection.
Choice D is wrong because using the balloon port to obtain the sterile specimen would deflate the balloon that holds the catheter in place and cause trauma to the bladder wall.
Normal ranges for urine characteristics vary depending on the type of analysis, but some general parameters are:
• Color: pale yellow to amber
• Clarity: clear or slightly cloudy
• Odor: faint aromatic
• pH: 4.5 to 8.0
• Specific gravity: 1.005 to 1.030
• Protein: <150 mg/24 hr
• Glucose: negative
• Ketones: negative
• Blood: negative
• Nitrites: negative
• Leukocyte esterase: negative
• Bacteria: <10,000 CFU/mL

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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 assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?

Correct Answer is C

Explanation

A nurse is caring for a client who has an indwelling urinary catheter. The nurse notes that sediment is present in the urine. Which of the following actions should the nurse take to obtain a sterile urine specimen?

Correct Answer is B

Explanation

A nurse is planning teaching for a client and their family about home oxygen therapy. Which of the following information should the nurse plan to include in the teaching?

A nurse is obtaining a client’s manual blood pressure and is having difficulty auscultating sounds. Which of the following actions should the nurse take?

A nurse is planning care for a school-age child who is 4 hr postoperative following appendicitis. Which of the following actions should the nurse include in the plan of care?

A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse?

A nurse is teaching a client who has rheumatoid arthritis about illness management. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a school-age child who is postoperative and received morphine via IV bolus for pain 10 min ago. Which of the following findings is the nurse’s priority?

A nurse is caring for a client who has cancer and is terminally ill. The client reports feeling depressed. Which of the following statements should the nurse make?