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."

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

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is "{\"xRanges\":[132,167],\"yRanges\":[113.5,148.5]}"

Explanation

A. This area corresponds to the trachea which produces bronchial breath sounds which are inconsistent with lower airway disease as expected in pneumonia.
B. This area corresponds to the right upper lung lobe which is accurate for auscultation for abnormal breath sounds such as crackles.
C. This area corresponds to the right upper quadrant for auscultation for bowel sounds.
D. This area corresponds to the cardiac region which is more accurate for auscultation of heart sounds.

Correct Answer is []

Explanation

Most Likely Condition: Deep Vein Thrombosis (DVT)
The client has multiple risk factors for developing a Deep Vein Thrombosis (DVT
• Recent surgery: The client is 2 days postoperative following a hysterectomy, which increases the risk of blood clots.
• Obesity: The client’s weight is 121.3 kg (267.4 lb), which significantly increases the risk of DVT
due to poor circulation and reduced mobility.
• Physical inactivity: The client has not yet ambulated much post-surgery due to significant pain, leading to stasis of blood in the lower extremities, which can increase the risk of clots.

• Smoking history: Smoking can damage blood vessels and increase clotting risk.
• Noncompliance with sequential compression devices (SCDs): The client reports that SCDs "hurt too much," and as a result, they are not wearing them. SCDs are a key prevention strategy against DVT, so nonuse of them further increases the risk.

Actions to Take

Check for pedal pulses and signs of ischemia:
DVT can lead to impaired circulation and ischemia in the affected limb. The nurse should assess for pedal pulses and signs of ischemia (e.g., coldness, swelling, pallor) to evaluate the extent of blood flow to the lower extremities. Early detection of impaired circulation can prevent complications like tissue damage.
Request a prescription for a lower-extremity Doppler flow study:
A Doppler ultrasound is the gold standard for diagnosing DVT. This non-invasive test uses sound waves to assess blood flow and detect clots. It should be ordered if the nurse suspects a DVT, especially with the client’s high risk factors.

Parameters to Monitor

Signs of bleeding after anticoagulation initiation:
If the client is diagnosed with a DVT, anticoagulants (e.g., heparin, warfarin, or enoxaparin) are often prescribed to prevent the clot from growing or migrating. The nurse needs to monitor for signs of bleeding (e.g., unusual bruising, bloody stools, or hematuria) as anticoagulant therapy increases bleeding risk.
Temperature:
Fever can be an indicator of infection or inflammation. If a DVT becomes complicated by phlebitis (inflammation of the vein) or if the clot is large or causes an infection, the client may develop a fever. Regular temperature monitoring is essential for detecting early signs of infection or complications related to DVT.

Rationale for incorrect conditions;
Muscle strain: While muscle strain can occur, the client’s presentation and risk factors (recent surgery, immobility, obesity) align more with DVT. Muscle strain is usually associated with localized pain, whereas DVT often presents with swelling, pain, and redness in the lower extremity, and potentially warmth.
Cellulitis: This is an infection of the skin and underlying tissues, typically presenting with redness, swelling, and warmth. The client does not exhibit these symptoms, and there’s no indication of an infection in the notes.
Heart failure: Heart failure can cause fluid retention, which leads to swelling in the extremities, but the
client’s vital signs (e.g., normal BP, heart rate, and respiratory rate) do not suggest heart failure. Additionally, the client does not report symptoms such as shortness of breath or chest pain.

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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 auscultating for crackles on a client who has pneumonia. Which of the following anterior chest wall locations should the nurse auscultate? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Correct Answer is "{\"xRanges\":[132,167],\"yRanges\":[113.5,148.5]}"

Explanation

Correct Answer is []

Explanation

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