A public health nurse is assessing an older adult client who lives with a family member.

The nurse identifies several bruises in various stages of healing. The client and family members explain that the bruises are a result of clumsiness. However, based on the distribution of the bruises, the nurse suspects abuse.

Which of the following actions should the nurse take first?

Investigate further to confirm the suspicion.

Report the findings.

Provide the client with a crisis hotline number.

Discuss respite care with the client’s family.

Answer and Explanation

The Correct Answer is B

The nurse has a legal and ethical obligation to report any suspected abuse of a vulnerable client, such as an older adult. Reporting the findings is the first action the nurse should take to protect the client and initiate an investigation by the appropriate authorities.

Choice A is wrong because investigating further to confirm the suspicion is not within the nurse’s scope of practice and could delay the reporting process.

Choice C is wrong because providing the client with a crisis hotline number is not enough to ensure the client’s safety and well-being.

The client might not be able to access the hotline or might be afraid to use it.

Choice D is wrong because discussing respite care with the client’s family is not appropriate at this stage.

The nurse should not assume that the family member is willing or able to provide adequate care for the client.

Respite care might be an option after the abuse is reported and investigated.

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Correct Answer is B

Explanation

This is because the nurse should not make assumptions about the family’s functionality based on their history or situation, but rather gather more information to identify their strengths and needs.

Choice A is wrong because it implies that the teenager is a problem and the mother is incapable of managing him, which is disrespectful and judgmental.

Choice C is wrong because it assumes that the mother is stressed and needs coping skills, which may not be true.

Choice D is wrong because it suggests that the mother is financially dependent on her son, which is not relevant to the question.

A. Folic acid deficiency anemia. B. Aplastic anemia. C. Vitamin B12 deficiency anemia. D. Acquired anemia.

Correct Answer is C

Explanation

This type of anemia is caused by the reduced absorption of vitamin B12 in the small intestine after gastric bypass surgery. Vitamin B12 is needed for the production of healthy red blood cells and nerve function. The symptoms of vitamin B12 deficiency anemia include sore tongue, tingling in the fingers, and balance problems.

Choice A is wrong because folic acid deficiency anemia is caused by the lack of folic acid in the diet or increased demand for folic acid, such as during pregnancy.

Folic acid is also needed for red blood cell production, but it does not cause nerve symptoms.

Choice B is wrong because aplastic anemia is caused by the failure of the bone marrow to produce enough blood cells.

It is not related to gastric bypass surgery or nutrient deficiency. It can be caused by infections, drugs, radiation, or autoimmune diseases.

Choice D is wrong because acquired anemia is a general term for any type of anemia that is not inherited or present at birth.

It can have many causes, such as blood loss, infection, inflammation, or chronic disease.

It does not specify the type of anemia or the underlying mechanism. Normal ranges for hemoglobin are 13.5 to 17.5 g/dL for men and 12 to 15.5 g/dL for women. Normal ranges for vitamin B12 are 200 to 900 pg/mL.

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Naxlex Comprehensive Predictor Exams

The RN learns that the father of a teenage client was killed in a car accident when he was a baby, and his mother has raised him on her own. How should the nurse interpret this family’s functionality?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

The nurse knows that infants have a high risk of hypothermia due to decreased brown fat, immature skin, and poorly developed thermoregulatory mechanism. Which nursing intervention is done to prevent heat loss by conduction?

A client’s bloodwork indicates that he has severe hypokalemia. What is a priority nursing intervention?

A nurse is cheering on participants in a marathon and one runner collapses nearby. He begins to vomit and complain of a throbbing headache. The nurse notes that he is not sweating, yet his skin is red and very hot to touch, and his pulse is 170 bpm and strong. The nurse knows that:

A nurse is caring for a client who has a cloudy, opaque area over the lens of one eye. The nurse should identify that this is a manifestation of which of the following visual impairments?

The nurse is performing a cultural assessment with a client; the nurse should include which of the following? (Select All That Apply).

The RN performs an admission assessment and determines the client is a fall risk. What is a priority nursing intervention for this client?

A nurse is teaching a newly licensed nurse about informed consent. Which of the following should be included as a responsibility of the nurse in this process?

The nurse is conducting an assessment on a client who is 36 hours postoperative following an appendectomy. During the assessment, the nurse is unable to hear any bowel sounds. The client denies passing flatus (gas). Given this information, which action is most appropriate by the nurse?