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 A

Explanation

A. Wearing loose-fitting underwear helps keep the genital area dry and prevents irritation, which can reduce the risk of urinary tract infections (UTIs).
B. The client should void every 2 to 3 hours during the day to help prevent UTIs.
C. The client should drink more fluids, typically 8 glasses (240 mL) or more, to help flush out bacteria from the urinary tract.
D. Bubble baths should be avoided as they can irritate the urinary tract and increase the risk of UTIs.

A. "How long have you been hearing the voices?" B. "I realize the voices are real to you, but I don't hear anything." C. "What are the voices telling you?" D. "Have you taken your medication today?"

Correct Answer is C

Explanation

A. While it is important to assess the duration of symptoms, it is more important to understand the content and context of the voices to determine potential risks.
B. Acknowledging that the voices are real to the client, while not hearing them, shows empathy and avoids invalidating the client's experience.
C. Understanding what the voices are saying helps assess the potential for harm and allows for appropriate intervention.
D. While checking on medication adherence is important, it does not address the immediate concern of what the voices may be telling the client.

View Question and Answer

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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 creating a plan of care for a female client who has recurrent urinary tract infections. Which of the following interventions should the nurse include in the plan?

Correct Answer is A

Explanation

A nurse is admitting a client who has schizophrenia. The client states, "I'm hearing voices." Which of the following responses is the priority for the nurse to state?

Correct Answer is C

Explanation

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