A nurse is caring for an older adult client.
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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." |
expressing concern over memory and thought process, appetite, and self-care
lost about 8 lb in the past month
"Why don't you just leave me? I am of no use."
speaks in a monotone voice
The Correct Answer is ["A","B","C"]
- This is a concerning finding because the adult child reports cognitive and physical decline in the client, which could indicate severe memory loss, cognitive impairment, or potentially dementia or other mental health conditions such as depression or suicidal ideation.
- Significant weight loss and decreased appetite in an older adult can indicate serious conditions, including malnutrition, depression, or potentially serious medical conditions such as cancer or other chronic diseases. Immediate follow-up is needed to assess the cause of the weight loss, evaluate the client’s nutritional status, and address any underlying health concerns.
- This statement is concerning because it suggests the client may be experiencing depression or suicidal ideation. Older adults are particularly vulnerable to depression, and this expression of worthlessness is a red flag that the client could be at risk for suicide. The nurse shouldimmediately assess the client’s mental health status, ask about thoughts of self-harm, and potentially initiate a psychiatric evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E","F","H"]
Explanation
A. Smoking marijuana to clear their mind
Using marijuana to cope with emotional pain or trauma is concerning. It suggests that the client may be turning to substances to manage their stress, anxiety, or trauma-related symptoms, which could lead to substance use disorder. It is important to address the substance use as it may hinder the healing process, especially given the trauma the client has experienced.
B. BP 122/80 mm Hg
This blood pressure reading is within the normal range for a 16-year-old. A blood pressure of 120/80 mm Hg or lower is generally considered normal for adolescents, so there is no immediate need for follow-up regarding this finding. This vital sign does not indicate an urgent issue.
C. Witnessing their family's death
Witnessing the violent deaths of close family members is a major traumatic event that can lead to post- traumatic stress disorder (PTSD), complicated grief, or other mental health issues. This experience is significant and requires immediate follow-up to assess how the client is processing the trauma and to ensure they are receiving appropriate mental health support, such as therapy or counseling.
D. Attends school regularly
While it's important to monitor the client’s social and academic functioning, attending school regularly is a positive indicator. The client is able to continue their education despite their trauma, which is a sign of resilience. However, this finding does not require immediate follow-up, but ongoing assessment may be needed to evaluate if there are any underlying issues affecting their school performance or social interactions.
E. Client experiences nightmares
Nightmares, particularly those related to a traumatic event, are a common symptom of post-traumatic stress disorder (PTSD). Since the client witnessed the traumatic deaths of their family members, this could be part of a larger pattern of distress. Follow-up is needed to evaluate the severity of the nightmares and determine whether the client needs trauma-focused therapy or other interventions to address potential PTSD symptoms.
F. Startles easily during thunderstorms
This is a common symptom of hypervigilance, which is associated with PTSD or acute stress disorder (ASD) following trauma. The client’s startle response, particularly in response to thunderstorms (which could be a trigger), warrants immediate follow-up. The nurse should assess the client's emotional response to stimuli and provide guidance on managing triggers, as well as explore whether the client needs therapy or trauma-informed care.
G. Heart rate 99/min
A heart rate of 99 beats per minute is within the normal range for adolescents and is not concerning on its own. While anxiety or stress could cause a mild increase in heart rate, this finding does not require immediate intervention unless there are other signs of distress, such as chest pain or difficulty breathing.
H. Caregiver reporting client acting differently than usual
A change in behavior, as reported by the caregiver, is concerning. It may indicate that the client is struggling emotionally or mentally, particularly after experiencing such a traumatic loss. This behavior could be linked to depression, anxiety, or trauma-related symptoms, and therefore requires immediate follow-up to assess the client's mental health and ensure that they are receiving appropriate support.
Correct Answer is B
Explanation
A. Loperamide is an anti-diarrheal medication and would not help with constipation.
B. Bisacodyl is a stimulant laxative that can help to stimulate bowel movements in a constipated client.
C. Magnesium hydroxide is a saline laxative but is not the first choice for postpartum constipation when the bowel has been inactive for several days.
D. Famotidine is an H2 receptor antagonist and is used to treat gastrointestinal issues, not constipation.
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