An older adult client is admitted to the hospital from a skilled care facility with dehydration and malnourishment. The client is oriented times four, but is despondent and withdrawn. The practical nurse (PN) observes that the client has multiple bruises on both arms and has poor hygiene. Which action should the PN implement first?

Document suspected abuse using the physical findings as supporting evidence.

Establish trust with the client to ensure basic needs and open communications are met.

Medicate the client as prescribed to ensure adequate rest and interventional therapies.

Contact social services to investigate the personnel at the skilled care facility.

Answer and Explanation

The Correct Answer is B

A. While documentation is essential, establishing a trusting relationship with the client is a more immediate priority to address their basic needs and gather information.
B. Establishing trust with the client is crucial to ensure their basic needs are met and to create an environment where the client feels safe to communicate openly. This foundational step is necessary before other interventions can be effectively implemented.
C. Medicating the client as prescribed is important for their overall care but does not address the immediate need to build trust and assess their situation comprehensively.
D. Contacting social services is a necessary step if abuse is suspected, but it should follow the initial assessment and establishment of trust with the client to gather accurate information.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. While knowing the number of tablets taken is important for managing chest pain, it is secondary to ensuring that the client can safely administer the medication.
B. Assessing the client's level of orientation and compliance is crucial because the client needs to understand how and when to use the nitroglycerin properly. Misunderstanding or non-compliance could lead to ineffective treatment or potential harm.
C. Checking heart rate and blood pressure is important for assessing the effects of nitroglycerin, but before leaving the medication for self-administration, it is vital to ensure that the client understands how to use the medication.
D. Monitoring hourly urinary output and daily weight is not relevant to the immediate concern of ensuring safe and effective nitroglycerin self-administration.

A. Report any foot injury or sore that does not readily heal. B. After washing feet, dry thoroughly between toes. C. Make sure shoe size fits to minimize rubbing and blisters. D. Monitor fingerstick glucose daily for tight control.

Correct Answer is A

Explanation

A. Reporting any foot injury or sore that does not readily heal is the most crucial instruction for minimizing long-term complications in diabetes management. Poor circulation and neuropathy in diabetic patients can lead to serious complications from minor foot injuries, so prompt medical evaluation is essential for preventing severe outcomes.
B. Drying feet thoroughly between toes is important for preventing fungal infections, but it is a standard part of foot care rather than a primary measure for preventing long-term complications like ulcers or infections.
C. Ensuring that shoe size fits to minimize rubbing and blisters is important for foot health, but it is not as critical as promptly addressing any injuries or sores that may arise.
D. Monitoring fingerstick glucose daily for tight control is necessary for diabetes management but does not directly address foot care issues. It is important for overall disease management but not specifically for immediate foot care concerns.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Which foot care instruction is most important for the practical nurse (PN) to reinforce that minimizes a long-term complication for a client who is newly diagnosed with type 2 diabetes mellitus (DM)?

Correct Answer is A

Explanation

A client with Parkinson's disease is experiencing decreased postural reflexes, rigidity, retropulsive gait, and shuffling. Which intervention is most important for the practical nurse (PN) to implement?

An older adult client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The practical nurse (PN) notes that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the PN to implement?

Exhibits What factors are important in determining level of hypoxemia that the child may have experienced during the submersion? Select all that apply.

The practical nurse (PN) is assessing an older adult client with left-sided heart failure (HF). Which intervention is most important for the PN to implement?

The practical nurse (PN) is documenting the insertion of a urinary catheter for a female client with urinary retention. What information should the PN include during the electronic documentation of the procedure? Select all that apply.

The practical nurse (PN) observes an unlicensed assistive personnel (UAP) obtain a client's vital signs. The PN should intervene when observing the UAP performing which technique?

The practical nurse (PN) positions a temporal artery scanner as seen in the picture. Before obtaining a temperature measurement, which assessment of the skin should the PN complete?