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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

The HOPE Tool for spiritual assessment is a questionnaire that explores the sources of hope, meaning, comfort, strength, peace, love, and connection for patients in healthcare settings. It does not ask about the correctness of one’s belief, but rather about the relevance and importance of one’s spirituality to one’s overall health and well-being. Therefore, choice B is not part of the HOPE Tool.

Choice A is wrong because it is part of the HOPE Tool. It asks about the personal spirituality and practices of the patient.

Choice C is wrong because it is part of the HOPE Tool. It asks about the organized religion or spiritual community of the patient.

Choice D is wrong because it is part of the HOPE Tool. It asks about the sources of hope or sustenance for the patient.

Normal ranges are not applicable to this question as it is not a numerical or quantitative measure.

A. Closing doors and windows to prevent draft (current of air with motion). B. Keeping a hat on the baby’s head. C. Thoroughly drying infant after a bath. D. Placing a warm blanket on the scale prior to obtaining baby’s weight.

Correct Answer is D

Explanation

This is because heat loss by conduction occurs when two objects with different temperatures come into direct contact with each other. The baby’s skin would lose heat to the cold scale by conduction if there was no warm blanket between them.

Choice A is wrong because closing doors and windows to prevent draft (current of air with motion) would prevent heat loss by convection, not conduction. Convection is the transfer of heat from a body to moving molecules such as air or liquid.

Choice B is wrong because keeping a hat on the baby’s head would prevent heat loss by radiation, not conduction. Radiation is the transfer of heat from a body to the surroundings by electromagnetic waves.

Choice C is wrong because thoroughly drying infant after a bath would prevent heat loss by evaporation, not conduction. Evaporation is the process of liquid changing into gas and carrying away heat from the body surface.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

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?

Correct Answer is D

Explanation

The nurse utilizes the SBAR format to give report to the next nurse. Which one of the following statements is correct about the SBAR?

A nurse is preparing an in-service presentation about preventing health care associated infections (HAIs). The nurse should include which of the following as a common cause of these infections?

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

The RN identifies that a client is at risk for impaired skin integrity. Which interventions should the nurse add to this client’s plan of care?

Which thermoregulatory condition is an elderly person most at risk for?

A nurse is caring for a patient who has complaints of fatigue. If the fatigue is caused by lifestyle choices, what should the nurse recommend for fatigue prevention? (Select all that apply)

Signs of hemolytic anaemias include:

A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse’s priority?