Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

Answer and Explanation

The Correct Answer is []

Condition: Elder maltreatment 2 actions: Initiate a referral to adult protective services; Administer prescribed pain medication 2 parameters: Frequency and severity of bruises; Nutritional intake and weight

Rationale for correct condition The client’s physical signs (multiple bruises in various stages, unclean appearance), social indicators (dependency, financial control, food insecurity), and behavioral changes in the presence of the caregiver strongly suggest elder abuse. Elder maltreatment includes physical, emotional, financial, and neglectful harm. An 82-year-old with a BMI of 18.3 shows undernutrition. His improved demeanor away from the child reflects psychological coercion. Bruises in different stages may indicate repeated trauma over time.

Rationale for correct actions Referral to adult protective services ensures legal and social intervention and facilitates multidisciplinary evaluation for safety. Reporting is mandated and protects the client from further harm. Administering pain medication addresses acute injury (fracture of right radius) and helps restore comfort. Effective pain management is crucial for mobility and assessment of additional injuries.

Rationale for correct parameters Monitoring bruising patterns helps identify ongoing abuse and quantify recovery or new trauma. Repeated injuries in various healing stages are hallmark signs. Nutritional intake and weight reflect neglect; insufficient food intake leads to weight loss and reduced immune function. Tracking BMI and calorie intake can guide long-term recovery and support.

Rationale for incorrect conditions Osteoporosis-related fracture would more likely occur with minimal trauma and does not explain social neglect or emotional signs. Accidental fall may be plausible but lacks explanation for systemic neglect and coercion. Peripheral neuropathy doesn’t explain acute arm pain or psychosocial signs of neglect.

Rationale for incorrect actions Encouraging activity is inappropriate during acute fracture recovery and potential abuse. Bone density scans assess fragility but don’t address safety risks. Nutritional supplements may help but don’t resolve underlying maltreatment or acute injury.

Rationale for incorrect parameters Bone density is not immediately relevant and doesn't reflect maltreatment. Blood pressure fluctuations are not present and don’t indicate abuse. Grip strength cannot be assessed accurately with an arm fracture and isn't useful for abuse evaluation.

Take-home points • Elder maltreatment includes physical harm, neglect, emotional abuse, and financial exploitation • Victims may show improved responsiveness when abuser is absent • Multidisciplinary intervention via adult protective services is critical • Differentiation from accidental injury ensures proper protection and care

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Correct Answer is C

Explanation

Choice A rationale

The shoulder harness straps should be positioned at or below the infant's shoulders when using a rear-facing car seat. This placement ensures that the crash forces are distributed across the strongest parts of the body and prevents the baby from sliding up out of the straps during an impact.

Choice B rationale

The retainer clip, or chest clip, should be placed at the level of the armpits, across the sternum. This position ensures that the shoulder straps remain securely on the shoulders and prevents the baby from being ejected from the harness in the event of a collision. Placing it on the abdomen can cause serious injury.

Choice C rationale

A 45-degree angle in a rear-facing car seat is a crucial safety measure. This reclined position ensures that the infant's airway remains open and unobstructed. It prevents the head from slumping forward, which could lead to positional asphyxiation, especially in newborns who lack strong neck control.

Choice D rationale

Current safety recommendations advise keeping a child rear-facing for as long as possible, until they reach the maximum height or weight limits of their car seat, which is typically well beyond one year of age. Turning the seat forward-facing at 1 year is no longer considered the safest practice. *.

A. Place of birth. B. Room number. C. Driver license number. D. Telephone number.

Correct Answer is D

Explanation

Choice D rationale

The telephone number is considered a reliable client identifier because it is unique to the individual and typically part of their personal health record. Using multiple identifiers, such as the telephone number in conjunction with the client's name and date of birth, is a critical safety measure to prevent medication errors and ensure the right medication is administered to the right client. This process, known as the "two-identifier rule," is a cornerstone of client safety protocols and aligns with guidelines from organizations like The Joint Commission

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Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching the guardian of a newborn about car seat safety. Which of the following statements by the guardian indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is preparing to administer medication to a client. Which of the following identifiers should the nurse use to identify the client?

Correct Answer is D

Explanation

A nurse is planning care for a client who has a history of urinary tract infections (UTIs) and requires placement of an indwelling urinary catheter. Which of the following actions should the nurse take to help minimize the client's risk for acquiring a UTI?

A nurse performs a capillary blood glucose check for a client who has type 1 diabetes mellitus and obtains a reading of 64 mg/dL on the glucometer. Which of the following assessment findings should the nurse expect?

A nurse is providing dietary teaching to the guardian of a preschooler who has celiac disease. Which of the following foods should the nurse recommend including in the preschooler's diet?

A nurse is teaching a client who has osteoarthritis about joint protection strategies. Which of the following instructions should the nurse include?

The nurse is preparing to speak to the facility’s social worker about the client’s condition. Select the 5 findings the nurse should plan to include in the report.

A nurse is teaching a client who has a new prescription for tetracycline. Which of the following information should the nurse include in the teaching?

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A nurse is providing dietary teaching to the guardian of a preschooler who has celiac disease. Which of the following foods should the nurse recommend including in the preschooler's diet?