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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 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."

"My sibling and I hired help at home for my parent.

I found the title to the car today, signed over to me."

Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression.

Client says, "Why don't you just leave me? I am of no use."

Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom."

Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min

Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 Ib in the past month.

Heart rate 68/min

Answer and Explanation

The Correct Answer is ["B","C","D","G"]

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."

Rationale

These findings suggest significant cognitive and physical decline, potential depression, and possible suicidal ideation, all of which require immediate attention and intervention.

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Free Nursing Study Resources

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

Explanation

Capillary refill 4 seconds: A prolonged capillary refill time of more than 2 seconds may indicate poor perfusion, possibly due to dehydration or circulatory compromise. This warrants immediate follow-up to assess for potential dehydration or shock.

Hyperactive bowel sounds: This may indicate gastrointestinal distress, such as diarrhea or irritation.

Diaper area erythema: Diaper rash is common in toddlers, particularly with diarrhea. Extremities cool: Cool extremities can be a sign of poor peripheral circulation, often associated with dehydration or developing hypovolemic shock. Immediate intervention is needed to address potential circulatory issues.

Reports no tears: The absence of tears, especially in a toddler, may suggest significant dehydration. This is a concerning sign and requires immediate follow-up to assess the child's hydration status and consider interventions, such as IV fluids or electrolyte management.

Lethargic: The child's lethargy, especially after vomiting and with decreased responsiveness, raises concern for potential dehydration, electrolyte imbalance, or a worsening condition. Lethargy in a toddler requires prompt evaluation and intervention to prevent further deterioration.

A. Speak in a normal voice at a natural pace. B. Pause in the middle of sentences. C. Direct statements to the interpreter. D. Use gestures when speaking with the client.

Correct Answer is A

Explanation

A. Speak in a normal voice at a natural pace: This allows the interpreter to accurately convey the nurse's message without confusion or misinterpretation. Speaking slowly or loudly is unnecessary and can be perceived as disrespectful.

B. Pause in the middle of sentences: Pausing mid-sentence may result in incomplete or confusing information being relayed to the client.

C. Direct statements to the interpreter: The nurse should direct communication to the client to maintain engagement and respect.

D. Use gestures when speaking with the client: Gestures can be misinterpreted, and relying on them reduces clear verbal communication.

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Body Systems	Findings
Respiratory	Respiratory rate 26/min
Cardiovascular	Heart rate 112/min Capillary refill 4 seconds
Gastrointestinal	Hyperactive bowel sounds
Integumentary	Diaper area reddened with erythema noted Extremities cool Reports no tears
Neurologic	Lethargic

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

A nurse is caring for a client who speaks a different language than the nurse and is using an interpreter. Which of the following actions should the nurse take when working with the interpreter?

Correct Answer is A

Explanation

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