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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Correct Answer is ["B","C","D","E"]

Explanation

A. Refuting delusions using logic can increase agitation and confusion. Instead, the nurse should offer reassurance and validation without arguing.
B. Giving the client one simple direction at a time helps minimize confusion and enhances the client’s
ability to follow instructions.
C. Establishing eye contact is important for communication and shows attentiveness, helping the client feel connected.
D. Allowing the client to choose among activities provides a sense of autonomy and can reduce agitation.
E. Reinforcing orientation helps maintain the client’s awareness of time, place, and person, which can reduce disorientation and anxiety.

A. "Do you have thoughts of harming yourself?" B. "How do you manage your behavior?" C. "Do you have a criminal record?" D. "How do you get along with your peers at school?"

Correct Answer is A

Explanation

A. The priority for any client, especially one with conduct disorder, is to assess for suicidal ideation or self-harm, which can be life-threatening.
B. Managing behavior is important, but safety concerns take precedence.
C. A criminal record is relevant but not the priority over immediate safety concerns.
D. Assessing peer relationships is important but secondary to evaluating immediate risks.

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 planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

Correct Answer is ["B","C","D","E"]

Explanation

A nurse in an emergency department is assessing an adolescent who has conduct disorder. Which of the following questions is the priority for the nurse to ask the client?

Correct Answer is A

Explanation

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