A nurse is caring for an older adult client.
Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.
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System |
Findings |
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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." |
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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 |
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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
The Correct Answer is ["A","B","C","D","E"]
The findings that require immediate follow-up are:.
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- 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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is because bleeding after a cardiac catheterization is a possible complication that can occur when a catheter is inserted into an artery in the groin or arm to examine the heart. Bleeding can drip or spurt from the puncture site, or form a lump under the skin called a hematoma. Applying continuous pressure above the site can help stop the bleeding and prevent hematoma formation.
Choice A is wrong because applying intermittent pressure 2.5 cm (1 in) above the percutaneous skin site may not be enough to control the bleeding and may increase the risk of hematoma.
Choice B is wrong because applying intermittent pressure 2.5 cm (1 in) below the percutaneous skin site may not be effective and may cause more damage to the artery.
Choice C is wrong because applying continuous pressure 2.5 cm (1 in) below the percutaneous skin site may also be ineffective and harmful to the artery.
Correct Answer is D
Explanation
This is because after puncturing the skin and the vein, the nurse needs to advance the catheter into the vein with the finger hub to ensure proper placement and prevent complications such as infiltration or phlebitis.
Choice A is wrong because flushing the catheter with saline should be done after securing the catheter to the skin with a transparent dressing and attaching a primed piece of extension tubing to the catheter.
Choice B is wrong because retracting the stylet should be done after advancing the catheter into the vein and releasing the tourniquet from the client’s arm.
Choice C is wrong because releasing the tourniquet should be done after advancing the catheter into the vein and before retracting the stylet.
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