Try Naxlex NCLEX-RN (Free-Trial)

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. A cool mist tent may be helpful for other respiratory conditions but is not the priority in epiglottitis.

B. Suctioning the oropharynx can cause further airway irritation and increase the risk of airway obstruction.

C. Epiglottitis can rapidly lead to airway obstruction, and intubation may be necessary to secure the airway.

D. Obtaining a throat culture is contraindicated as it may trigger airway closure.

A. Sinus tachycardia B. Atrial fibrillation C. Second-degree heart block D. Ventricular asystole

Correct Answer is B

Explanation

A. Sinus tachycardia: Incorrect. Sinus tachycardia shows a regular rhythm with identifiable P waves, not a wavy baseline.

B. Atrial fibrillation: The wavy baseline and absent P waves are characteristic of atrial fibrillation, a common arrhythmia that results from rapid and irregular electrical activity in the atria.

C. Second-degree heart block: Incorrect. Second-degree heart block would show P waves with intermittent conduction of the QRS complex, not a wavy baseline.

D. Ventricular asystole: Incorrect. Ventricular asystole would show no electrical activity, which is different from a wavy baseline.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is caring for a 3-year-old child who has suspected epiglottitis. Which of the following actions should the nurse include in the plan nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who is alert and oriented and is receiving continuous ECG monitoring. The cardiac rhythm strip shows a wavy baseline, no distinguishable P waves, and an increased heart rate. The nurse should identify the cardiac rhythm as which of the following?

Correct Answer is B

Explanation

A nurse is caring for a client who has a stool culture that is positive for Clostridium difficile. Which of the following infection control precautions should the nurse take?

A nurse is caring for a client who has a placenta previa. Which of the following findings should the nurse expect?

A nurse is providing discharge instructions to a client who has a new prescription for haloperidol. Which of the following adverse effects should the nurse instruct the client to report to the provider?

A nurse in an outpatient mental health clinic is assessing an adolescent client. The nurse should expect the adolescent to be in which of the following of Erikson's stages of psychosocial development?

A nurse is caring for a client who has heart failure. Which of the following manifestations should the nurse expect?

A nurse is reviewing the client's electronic medical record. Exhibits Which of the following findings require follow up? Select all that apply.

A nurse is preparing to administer the first dose of cefazolin via intermittent Ivrder and refuses to take their medication. Which of the following nurse take first?