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 ["A","C","D"]

Explanation

Choice A is correct because maintaining a regular sleep routine can help regulate your circadian rhythm, which is your body’s natural sleep-wake cycle. This can improve the quality and quantity of your sleep and reduce daytime sleepiness.

Choice B is wrong because eating three large meals a day can cause fluctuations in your blood sugar levels, which can affect your energy levels. It is better to eat smaller, more frequent meals and snacks that contain a balance of protein and carbohydrates to keep your blood sugar stable and provide sustained energy. Choice C is correct because limiting refined sugar, fried foods and processed foods can help prevent fatigue by reducing inflammation and oxidative stress in your body.

These foods can also cause spikes and crashes in your blood sugar levels, which can make you feel tired and hungry. Instead, you should eat more anti-inflammatory foods, such as fruits, vegetables, nuts, seeds and fish.

Choice D is correct because taking daily walks can help prevent fatigue by increasing your blood circulation, oxygen delivery and endorphin production. Exercise can also improve your mood, sleep quality and immune system.

Choice E is wrong because increasing caffeine intake can have the opposite effect of preventing fatigue.

Caffeine is a stimulant that can temporarily boost your energy levels, but it can also disrupt your sleep, cause dehydration, increase anxiety and lead to withdrawal symptoms

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

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)

Correct Answer is ["A","C","D"]

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 knows that the first-line treatment for localized inflammation (for example, on a patient’s ankle) is RICE. This acronym means:

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?

The nurse identifies chronic pain as an appropriate nursing priority (or problem/diagnosis) for a client with fibromyalgia. Which manifestation did the client most likely report that caused the nurse to select this priority?

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?

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?