A nurse is caring for an older adult client being admitted into a long-term care facility.

Exhibits

Complete the following sentence by using the list of options.

The nurse should address the client's
dropdown
followed by
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Rationale for correct choices:

Safety: The client has an unsteady gait, dizziness on standing, ecchymosis in multiple healing stages, and abrasions, all of which raise concerns for recurrent falls or possible neglect. Ensuring the client’s immediate safety is the top priority before addressing other needs.
Notify Adult Protective Services: Scattered ecchymoses in different healing stages, poor hygiene, and possible neglect warrant a report to APS for further investigation to ensure the client’s protection.

Rationale for incorrect choices:

Hygiene: While poor hygiene, lice infestation, and odor are evident, these concerns are not immediately life-threatening compared to the safety risks of falls and potential abuse or neglect. They can be addressed after the client is safe and protected.
Nutrition: No clear evidence of malnutrition is provided, though decreased skin turgor suggests possible dehydration. However, nutrition needs are a lower priority than immediate safety concerns related to falls and potential abuse.
Arrange for dietary consult: This intervention would be appropriate later for long-term care planning, but it does not address the client’s most urgent risk factors.
Consult with social services for support: Social services may help coordinate resources, but urgent reporting to APS is needed first because of suspected neglect and abuse indicators.

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Correct Answer is D

Explanation

A. Witnessing a client's signature for informed consent: Witnessing consent is a legal responsibility, not an advocacy role. The nurse verifies the client’s signature but does not address the client’s needs or ensure their voice is represented in care decisions.

B. Instructing a client about how to apply antiembolic stockings: Teaching a client is part of health promotion and nursing education. While important, it does not represent advocacy since it does not involve speaking up or acting on behalf of the client’s expressed needs.

C. Ensuring that all clients receive equal treatment: Providing equitable care is an ethical obligation for all nurses but does not fully represent advocacy. Advocacy specifically involves acting on a client’s behalf when barriers or unmet needs are identified.

D. Requesting a social services consultation for a client who states they cannot afford their medications: This is advocacy because the nurse is acting on the client’s expressed concern and connecting them to resources that address barriers to care. It ensures the client’s health needs are supported beyond routine clinical interventions.

A. 30° lateral B. Lateral semi-prone recumbent C. Supine D. 45° supported Fowler's

Correct Answer is A

Explanation

A. 30° lateral: The 30-degree lateral position is recommended to reduce pressure on bony prominences such as the trochanters, sacrum, and heels. It distributes weight more evenly and decreases the risk of pressure injury compared to lying directly on the side or back.

B. Lateral semi-prone recumbent: This position places significant pressure on the greater trochanter and shoulder, which increases the risk of skin breakdown. It is not the safest choice for clients at high risk of pressure injuries.

C. Supine: Lying flat on the back concentrates pressure on the sacrum, heels, and occiput. Prolonged supine positioning without frequent repositioning contributes to rapid development of pressure injuries.

D. 45° supported Fowler's: While Fowler’s position can help with breathing, it increases pressure on the sacrum and ischial tuberosities. Extended use in this position places immobile clients at a greater risk for pressure injuries.

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A nurse is caring for an older adult client being admitted into a long-term care facility. Exhibits Complete the following sentence by using the list of options. The nurse should address the client's dropdownfollowed bydropdown.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is providing an in-service about client advocacy to a group of newly licensed nurses. Which of the following examples should the nurse include?

Correct Answer is D

Explanation

A nurse is caring for a client who is at risk for pressure injury formation due to immobility. The nurse should place the client in which of the following positions to reduce pressure on the client's bony prominences?

Correct Answer is A

Explanation

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A nurse is caring for an older adult client being admitted into a long-term care facility.

Exhibits

Complete the following sentence by using the list of options.

The nurse should address the client's
dropdown
followed by
dropdown
.