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 D

Explanation

Withholding food and oral fluids until intestinal mobility has returned. This is because the client may have postoperative ileus (POI), which is a reduction of gastrointestinal motility after abdominal surgery. POI is characterized by abdominal distension, lack of bowel sounds, accumulation of gas and fluids in the bowel, and delayed passage of flatus and stools.

Giving food and fluids to a client with POI may worsen the condition and cause complications.

Choice A is wrong because high fat foods may slow down GI motility and increase the risk of constipation.

Choice B is wrong because solid food intake may also aggravate POI and cause abdominal discomfort.

Choice C is wrong because fiber intake may increase gas production and distension in the bowel. The nurse should auscultate the abdomen for bowel sounds, and if they are present, or the client reports passing flatus, clear fluids can commence, and aperients can be administered. However, bowel sounds are not a reliable indicator of the end of POI, as they may not be associated with the time of first flatus.

Therefore, withholding food and oral fluids until intestinal mobility has returned is the most appropriate action by the nurse.

A. Protecting the client’s bones with strict bedrest. B. Providing the client with assisted range of motion exercises twice daily. C. Decreasing the amount of calcium in the client’s diet. D. Increasing regular weight-bearing activities.

Correct Answer is D

Explanation

Increasing regular weight-bearing activities can help prevent osteoporosis by stimulating bone formation and improving muscle strength. Weight-bearing activities are those that make your bones and muscles work against gravity, such as walking, jogging, dancing, or lifting weights.

Choice A is wrong because protecting the client’s bones with strict bedrest can actually increase the risk of osteoporosis by reducing bone density and muscle mass. Bedrest should be avoided unless medically necessary.

Choice B is wrong because providing the client with assisted range of motion exercises twice daily is not enough to prevent osteoporosis. While these exercises can help maintain joint mobility and flexibility, they are not weight bearing and do not stimulate bone formation.

Choice C is wrong because decreasing the amount of calcium in the client’s diet can also increase the risk of osteoporosis. Calcium is an essential mineral for bone health and adults need 700mg a day, which can be obtained from foods such as dairy products, leafy green vegetables, tofu, and dried fruit. Vitamin D is also important for bone health as it helps the body absorb calcium.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

A client who is at risk for developing osteoporosis asks what can be done to decrease the risk of actually developing the disorder. Which intervention would be the most beneficial for this client?

Correct Answer is D

Explanation

Which of the following nursing diagnoses would typically NOT be associated with anemia?

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 does not turn a client every two hours as ordered, and the client develops a pressure injury. What legal concept applies?

The nurse educator is presenting information to a group of nursing students regarding uninsured and underinsured clients. The nurse educator emphasizes that a lack of insurance or lack of sufficient insurance is:

A nurse is teaching about values to a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding?

The nurse graduate is reviewing his scope of practice. Which of the following does he correctly identify as outlining the legal scope of practice for nursing?

The nurse is assigned to care for a client admitted to the hospital with chronic obstructive pulmonary disease (COPD). Which medication does the nurse anticipate to decrease this client’s risk for developing a respiratory infection?

A diabetic client presents to the acute care facility for the amputation of two gangrenous digits on her left foot. Which type of perfusion issue has caused this condition?