An older adult client who reports pain in the arms and back is brought to the emergency department (ED) by an adult child who states the client "fell out of a chair." The nurse notes that the client has been in the ED five times in the last year for a variety of superficial injuries. Which nursing action has the highest priority?

Request social services to make a home visit.

Interview the client privately without the adult child present.

Complete a neurological and musculoskeletal assessment.

Ask the client if an assisted living facility is an option for safety concerns.

Answer and Explanation

The Correct Answer is B

A. Request social services to make a home visit. This is important but not the immediate priority. It can be part of the long-term intervention plan once the immediate safety and health of the client are ensured.

B. Interview the client privately without the adult child present. This is the highest priority. It allows the nurse to assess for potential abuse or neglect without the influence or intimidation of the accompanying adult, ensuring the client can speak freely.

C. Complete a neurological and musculoskeletal assessment. This is important to assess the extent of the injuries and the client's overall physical health, but it follows the immediate need to ensure the client's safety and ability to speak freely about their situation.

D. Ask the client if an assisted living facility is an option for safety concerns. While exploring living arrangements is important for long-term safety, it is not the highest priority. Ensuring the client's immediate safety and obtaining accurate information about their situation takes precedence.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Kyphosis: A rounding of the upper back, causing a hunchback appearance. While it can also be caused by other conditions, a mild kyphosis is a common finding in older adults due to weakening muscles and spinal compression.

B. Barrel chest: This refers to a chest that is fixed in an outward position, often caused by chronic obstructive pulmonary disease (COPD) or other lung conditions.

C. Lordosis: An exaggerated inward curve of the lower back, which is not a typical feature of normal aging.

D. Pectus excavatum: A sunken appearance of the chest wall, usually a congenital condition present from birth.

A. Explain to the child the reasons an examination is needed. B. Talk to the parent and gradually focus on the child's toy. C. Complete the assessment while allowing the child to cry. D. Request extra staff to help with the nursing assessments.

Correct Answer is B

Explanation

A. Explaining the exam: Preschool-aged children might not fully understand the need for an exam, and this might not alleviate their anxiety.

B. Talking to parent and focusing on toy: This strategy prioritizes calming the child first. Talking to the parent helps gather information while the nurse gradually gains the child's trust by acknowledging their toy. This can create a more positive and collaborative environment.

C. Completing assessment while crying: This can be stressful for the child and might hinder an accurate assessment.

D. Requesting extra staff: While additional support might be helpful, the initial approach should focus on building rapport with the child.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment finding of an older adult client should the nurse associate with normal aging?

Correct Answer is A

Explanation

A parent brings a preschool aged client to the clinic because of having diarrhea, vomiting, and high fevers for the past three days. The child begins to cry and cling to the parent when the nurse enters the examination room. Which action should the nurse implement to get the child to cooperate?

Correct Answer is B

Explanation

A school-age child presents for a well-child visit with a hemoglobin level of 10 g/dL (100 g/L) and a body mass index of 15 kg/mm2. Which additional assessment should the nurse obtain to help identify a potential cause of these clinical manifestations?

Parents bring their 8-month-old child to the clinic because they are concerned that the child is not developing as an older sibling did. Which developmental characteristic should the nurse expect an 8-month-old to exhibit?

A pregnant, homeless woman who has received no prenatal care presents to the clinic in her third trimester because she is having vaginal bleeding, but reports that she is not in pain. Ultrasound reveals a placenta previa. Which action should the nurse implement?

The nurse is caring for a client who has been diagnosed with malnutrition. Which finding supports the medical diagnosis?Reference Range: Body Mass Index (BMI) (18.5 to 24.9 kg/m3]

While completing a health assessment for a client being admitted with bilateral pneumonia, the nurse asks the client to describe the sputum. Which communication technique should the nurse use to obtain this information?

The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life?

The nurse is assessing a client who is having pain of the right upper abdominal area. To assess the quality of the client's abdominal pain, which approach should the nurse use?

While the nurse is obtaining a health history, the client reports experiencing shortness of breath at times. The nurse determines that the client's respirations are regular and deep and respiratory rate is 14 breaths/minute. Which is the best nursing action?