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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."

A.

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

B.

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

C.

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

D.

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

E.

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

F.

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

G.

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

H.

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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Related Questions

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

  • Evaluating the fetal heart rate tracing: This is crucial to assess the well-being of the fetus, especially given the client's report of decreased fetal movement.
  • Administering magnesium sulfate IV: This is important for managing severe preeclampsia and preventing seizures.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}

Explanation

Nursing action

Anticipated

Contraindicated

Obtain consent for cesarean birth

✅

Provide intermittent fetal heart rate monitoring

✅

Administer oxygen 10 L via face mask

✅

Prepare the client for an amnioinfusion

✅

Initiate IV bolus lactated Ringer’s

✅

Insert a urinary catheter

✅

Rationale:

Obtain consent for cesarean birth: This is anticipated because the client is presenting with uterine contractions, vaginal bleeding, and abdominal pain, which may indicate complications such as placental abruption or abnormal placental attachment, potentially requiring a cesarean birth for the safety of both the mother and fetus.

Provide intermittent fetal heart rate monitoring: This is anticipated as it is essential to monitor fetal well-being, especially with the reported minimal fetal heart rate variability and potential for fetal distress.

Administer oxygen 10 L via face mask: This is anticipated to improve oxygenation, especially if there is a risk of fetal distress or compromised perfusion due to maternal blood loss.

Prepare the client for an amnioinfusion: This is contraindicated in the setting of vaginal bleeding and suspected placental abruption, as amnioinfusion is typically used for conditions such as oligohydramnios, and it could increase the risk of additional complications in this case.

Initiate IV bolus lactated Ringer’s: This is anticipated as the client has signs of hypovolemic shock due to blood loss, and an IV bolus would be necessary to improve fluid volume and blood pressure.

Insert a urinary catheter: This is contraindicated unless clinically necessary, as urinary catheterization may not be indicated in the immediate management of placental issues or bleeding complications without further evaluation, and it could introduce an infection risk.

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