A nurse is caring for an older adult client.

Exhibits

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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

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. Administering a cathartic suppository 30 minutes prior to scheduled defecation times can help stimulate bowel movements in clients with spinal cord injuries, aiding in bowel training.
B. Refined grains can lead to constipation, and increasing fiber intake is typically preferred over refined grains in a bowel training program.
C. A cold drink is not a standard or recommended method to stimulate bowel movements in clients with spinal cord injuries.
D. Fluid intake should generally be higher than 1,500 mL per day, as adequate hydration is important to prevent constipation and support healthy bowel function.

A. Epistaxis B. Dizziness C. Shortness of breath D. Headache

Correct Answer is B

Explanation

A. Epistaxis (nosebleeds) is not a common manifestation of hypovolemia. It is more typically associated with conditions like hypertension or nasal trauma.
B. Dizziness is a common symptom of hypovolemia due to reduced blood volume and decreased perfusion to the brain.
C. Shortness of breath is more likely to occur with conditions such as pulmonary edema or respiratory disorders, not hypovolemia.
D. Headache can occur in hypovolemia due to reduced blood flow, but dizziness is more directly related to the body's inability to compensate for low blood volume.

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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 planning care for a client who has a prescription for a bowel-training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care?

Correct Answer is A

Explanation

A nurse is assessing a client who is experiencing hypovolemia. Which of the following manifestations should the nurse expect?

Correct Answer is B

Explanation

A nurse is preparing to administer a medication that is available in a glass ampule. Which of the following actions should the nurse plan to take?

A nurse is caring for a school-age child who is 2 hr postoperative following a cardiac catheterization. The nurse observes blood on the child's dressing. Which of the following actions should the nurse take?

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A nurse is providing discharge teaching about home care of a surgical incision to a client who speaks a different language from the nurse. The nurse is communicating with the client using an interpreter. Which of the following actions should the nurse take?

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A nurse is completing an admission assessment for a client who has narcissistic personality disorder. Which of the following findings should the nurse expect?

A nurse is caring for an adolescent who has hyperthermia. Which of the following actions should the nurse take?