A nurse is planning care for a school-age child who is 4 hr postoperative following appendicitis.

Which of the following actions should the nurse include in the plan of care?

Answer is B, C, D, E, F. These are the findings that suggest possible elder abuse or neglect.

• B: Client’s report of lack of food in home. This may indicate neglect by the adult child who is supposed to provide adequate nutrition for the client.
• C: Client’s report of lack of access to bank accounts. This may indicate financial abuse by the adult child who is controlling the client’s money without his permission.
• D: Client’s avoidance of eye contact. This may indicate emotional abuse by the adult child who is intimidating or threatening the client.
• E: Client’s report of weight loss. This may indicate neglect by the adult child who is not meeting the client’s basic needs or physical abuse by the adult child who is causing bodily harm to the client.
• F: Numerous bruises in various stages of healing. This may indicate physical abuse by the adult child who is hitting or injuring the client.

A: ECG results. This is not a finding that suggests elder abuse or neglect. It is a diagnostic test that measures the electrical activity of the heart and can help detect cardiac problems. It does not provide information about the client’s social or emotional well-being.

Normal ranges for vital signs:.

• Temperature: 36.1°C to 37.2°C (97°F to 99°F).
• Heart rate: 60 to 100 beats per minute.
• Blood pressure: less than 120/80 mm Hg.
• Respiratory rate: 12 to 20 breaths per minute.
• SpO2: 95% to 100% on room air. Table for BMI categories:

The client’s BMI is 18.3, which indicates he is underweight and may be malnourished or have a medical condition that causes weight loss.

The correct answer is choice A. INR.

Warfarin is a vitamin K antagonist that inhibits the synthesis of factors II, VII, IX, and X in the liver.

These factors are part of the extrinsic and common pathways of coagulation, which are measured by the prothrombin time (PT) and the international normalized ratio (INR).

The INR is a standardized way of reporting the PT that accounts for the variability of different reagents and instruments.

The INR is used to monitor the therapeutic effect of warfarin and to adjust the dose accordingly.

The target INR range depends on the indication for warfarin, but it is usually between 2 and 3 for most conditions.

Choice B is wrong because fibrinogen level is not affected by warfarin.

Fibrinogen is a precursor of fibrin, which forms the final step of the coagulation cascade.

Fibrinogen level can be decreased in conditions such as disseminated intravascular coagulation (DIC), liver disease, or severe bleeding. Choice C is wrong because aPTT is not affected by warfarin.

aPTT measures the intrinsic and common pathways of coagulation, which are mainly dependent on factors VIII, IX, XI, and XII.

These factors are not inhibited by warfarin.

aPTT is used to monitor the effect of heparin, a direct antithrombin agent that inhibits thrombin and factor Xa.

Choice D is wrong because platelet count is not affected by warfarin.

Platelets are cell fragments that adhere to damaged blood vessels and form aggregates to initiate hemostasis.

Platelet count can be decreased in conditions such as immune thrombocytopenia (ITP), heparin-induced thrombocytopenia (HIT), or bone marrow suppression.

Normal ranges:

• INR: 0.8-1.2
• Fibrinogen: 200-400 mg/dL
• aPTT: 25-35 seconds
• Platelet count: 150-450 x 10^9/L References: