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 The client is oriented times four, but is despondent and withdrawn.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.

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Correct Answer is B

Explanation

A. Isoniazid can cause side effects like peripheral neuropathy, but ringing in the ears is not a common symptom of this medication.
B. Gentamicin can cause ototoxicity, which includes symptoms such as ringing in the ears (tinnitus). This side effect is significant and should be reported to the healthcare provider for further evaluation.
C. Pyridoxine is used to prevent neuropathy caused by isoniazid and does not cause ringing in the ears.
D. Rifampin is an antitubercular medication but is not commonly associated with tinnitus as a side effect. The immediate concern with ringing in the ears is related to gentamicin.

A. Eggs. B. Broccoli. C. Spinach. D. Dairy products. E. Bananas.

Correct Answer is ["B","C"]

Explanation

A. Eggs are not a significant source of vitamin K. Foods rich in vitamin K are primarily green leafy vegetables and certain other plant-based foods.
B. Broccoli is a good source of vitamin K. It is rich in this nutrient, which plays a crucial role in blood clotting and bone health.
C. Spinach is an excellent source of vitamin K. It is one of the top leafy greens that provide this vitamin and supports various bodily functions.
D. Dairy products do not contain significant amounts of vitamin K. They are more associated with calcium and vitamin D.
E. Bananas are not a notable source of vitamin K. They are rich in potassium but not in vitamin K.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

What foods should the practical nurse (PN) recommend to a client as good sources of vitamin K? Select all that apply.

Correct Answer is ["B","C"]

Explanation

The practical nurse (PN) is caring for a client whose urine drug screen is positive for cocaine. Which behavior should the PN document as evidence of cocaine withdrawal?

Which location should the practical nurse (PN) palpate to determine if a client's submandibular lymph nodes are enlarged?

The practical nurse (PN) views the mid-line episiotomy of a client who reports pain in her stitches. Which action should the PN take first?

In administering a nitroglycerin transdermal patch to a client with chronic angina pectoris, in which order should the practical nurse (PN) carry out the actions? (Arrange from first action on top to last on the bottom.)

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

Exhibits The practical nurse (PN) has received report and is preparing to enter the room to assess the client. What personal protective equipment (PPE) should the PN don before entering the room? Select all that apply.

Exhibits Review H and P, nurse's note, laboratory results, prescriptions, and imaging studies. What complications should the practical nurse (PN) monitor for in the next 6 to 8 hours? Select all that apply.