An elderly client is admitted to the hospital looking unkempt, with dirty clothing, and she smells of urine.
The nurse is aware this may be:

Institutionalism.

Neglect.

Emotional abuse.

Stubborn behavior.

Answer and Explanation

The Correct Answer is B

Neglect refers to the refusal or failure to provide an elderly person with necessary care, such as food, water, shelter, personal hygiene, medicine, and other essentials of daily living. Signs and symptoms of neglect in elders can include: dehydration, malnutrition, bed sores, fractures, urinary tract infections, contractures, over-medication, elopements, and poor personal hygiene. An elderly client who is admitted to the hospital looking unkempt, with dirty clothing, and smelling of urine may be suffering from neglect by a caregiver or by themselves (self-neglect).

Choice A is wrong because institutionalism is not a type of elder abuse but a term that describes the loss of individuality and autonomy that can occur in institutional settings such as nursing homes.

Choice C is wrong because emotional abuse is the infliction of mental or emotional anguish by threat, humiliation, intimidation, or other abusive conduct. Signs and symptoms of emotional abuse in elders can include: depression, confusion, withdrawal, isolation from friends and family. An elderly client who smells of urine may not necessarily be emotionally abused.

Choice D is wrong because stubborn behavior is not a type of elder abuse but a personality trait that may or may not be present in an elderly person.

Stubborn behavior does not indicate any harm or neglect inflicted upon an older adult by others or themselves.

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Correct Answer is C

Explanation

his intervention can help prevent pressure ulcers by reducing the amount of pressure on bony prominences and promoting blood circulation to the skin.

Choice A is wrong because placing the patient in a side-lying position only can increase the risk of skin breakdown by limiting the patient’s mobility and exposing the same areas to pressure. The patient should be repositioned frequently and encouraged to change positions if able.

Choice B is wrong because massaging bony prominences can cause tissue damage and increase the risk of skin breakdown by impairing blood flow to the area. Massaging should be avoided over bony prominences and areas of redness.

Choice D is wrong because keeping the head of the bed elevated higher than 30 degrees can cause shearing forces on the skin, which can lead to skin breakdown. The head of the bed should be kept at the lowest degree of elevation possible.

Choice E is wrong because inspecting skin every shift is not enough for a patient at risk for impaired skin integrity. The skin should be inspected at least every 2 hours or more frequently depending on the patient’s condition. Early detection of skin changes can help prevent further damage and promote healing.

Normal ranges for skin integrity are:

• Skin color: consistent with ethnicity and genetic background, no pallor, cyanosis, or jaundice.

• Skin moisture: dry to touch, no excessive perspiration or dryness. • Skin texture: smooth, soft, intact, with even surface.

• Skin temperature: warm to touch, no hyperthermia or hypothermia. • Skin turgor: elastic, returns to original shape after being pinched. • Skin integrity: no lesions, wounds, abrasions, or ulcers.

A. Hourly vital signs. B. Implementing all fall risk precautions. C. Utilizing bariatric bed and trapeze bar. D. Supine positioning.

Correct Answer is C

Explanation

A patient with a BMI of 38 is considered to have obesity, which means they have excess body fat that may impair their mobility and increase their risk of complications such as pressure ulcers, infections, and respiratory problems. A bariatric bed is designed to accommodate the weight and size of obese patients, and a trapeze bar can help them change positions and transfer to a chair or wheelchair.

These interventions can promote comfort, safety, and independence for the patient.

Choice A is wrong because hourly vital signs are not necessary for a patient with obesity unless they have other conditions that warrant frequent monitoring.

Choice B is wrong because implementing all fall risk precautions may be excessive and restrictive for a patient with obesity who is otherwise stable and alert.

Choice D is wrong because supine positioning can compromise the patient’s breathing and circulation, and increase the risk of pressure ulcers and aspiration.

The patient should be encouraged to change positions frequently and elevate the head of the bed when lying down.

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An elderly client is admitted to the hospital looking unkempt, with dirty clothing, and she smells of urine. The nurse is aware this may be:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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An elderly client is admitted to the hospital looking unkempt, with dirty clothing, and she smells of urine.
The nurse is aware this may be: