Exhibits

The nurse is reviewing the client's data. Which of the following findings should the nurse report to the primary health care provider immediately? Select all that apply.

Blood pressure of 90/79 mm Hg with a pulse pressure less than 40 mm Hg

Oxygen saturation of 100% on 40% FiO₂

Heart rate of 128 beats/minute, sinus tachycardia

CT scan findings of liver and spleen lacerations with blood in the peritoneum

Temperature of 96.9°F (36.1°C)

Answer and Explanation

Correct Answer : A,C,D

Choice A rationale: Blood pressure of 90/79 mm Hg with a pulse pressure less than 40 mm Hg is concerning because it indicates hypotension and a narrowed pulse pressure, which can be signs of significant internal bleeding or shock. This requires immediate medical attention to stabilize the client's condition.

Choice B rationale: Oxygen saturation of 100% on 40% FiO₂ is not a critical finding that requires immediate reporting. The client is receiving sufficient oxygen, and the saturation level indicates adequate oxygenation.

Choice C rationale: Heart rate of 128 beats/minute, sinus tachycardia is an important finding because tachycardia can indicate a response to pain, anxiety, hypovolemia, or shock. It needs to be reported to assess and address the underlying cause.

Choice D rationale: CT scan findings of liver and spleen lacerations with blood in the peritoneum are critical because they indicate significant internal injuries and active bleeding. This requires immediate surgical intervention and close monitoring.

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Correct Answer is B

Explanation

Choice A rationale

Crushing zolpidem to increase absorption is inappropriate because it is a controlled-release medication. Crushing the tablet would disrupt the controlled-release mechanism, leading to rapid absorption, increased side effects, and potentially dangerous consequences.

Choice B rationale

Taking zolpidem before bedtime is correct because it is a medication prescribed for insomnia. It helps the patient fall asleep more quickly by acting on the central nervous system to induce sleep, and it should be taken when the patient is ready to sleep.

Choice C rationale

Administering zolpidem with a meal is not recommended. Food can delay the absorption of the medication, reducing its effectiveness in helping the patient fall asleep promptly.

Choice D rationale

Storing zolpidem at room temperature is correct, but it is not a critical point of patient education. The emphasis should be on taking the medication as prescribed and understanding its purpose and potential side effects.

A. Short term memory loss. B. Malnutrition. C. Bilateral leg edema. D. Diminished breath sound. E. Dark room lighting. F. Poor hygiene. G. Pressure injuries.

Correct Answer is ["B","E","F","G"]

Explanation

Choice A rationale

Short-term memory loss is not typically associated with elder mistreatment. It may result from normal aging, neurological conditions like Alzheimer's disease, or other medical issues affecting cognitive function. It does not directly indicate mistreatment.

Choice B rationale

Malnutrition in the elderly can be a sign of neglect or mistreatment, where the individual may not receive adequate nutrition due to inadequate caregiving or intentional withholding of food. It can lead to severe health complications and indicates a lack of proper care.

Choice C rationale

Bilateral leg edema can result from various medical conditions, such as heart failure, chronic venous insufficiency, or renal disease. It is not a specific indicator of elder mistreatment and requires a thorough medical evaluation to determine the underlying cause.

Choice D rationale

Diminished breath sounds are typically related to respiratory conditions, such as pneumonia, chronic obstructive pulmonary disease (COPD), or pleural effusion. While they require medical attention, they do not directly indicate elder mistreatment.

Choice E rationale

Dark room lighting can suggest poor living conditions and inadequate care, potentially indicating neglect or mistreatment. Proper lighting is essential for the safety and well-being of elderly individuals, and its absence may reflect a lack of proper care and attention.

Choice F rationale

Poor hygiene is a common sign of neglect in elder mistreatment cases. It indicates that the individual may not receive assistance with personal care, leading to physical and emotional distress. Neglecting hygiene needs can result in infections and other health issues.

Choice G rationale

Pressure injuries, or bedsores, are often a result of prolonged immobility and inadequate repositioning, which can occur in cases of elder mistreatment or neglect. These injuries can lead to severe complications and are indicative of a lack of proper care and attention to the individual's needs.

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Exhibits The nurse is reviewing the client's data. Which of the following findings should the nurse report to the primary health care provider immediately? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing education to a client who receives a prescription for zolpidem. Which information about the medication should the nurse include?

Correct Answer is B

Explanation

The nurse recognizes that findings consistent with elder mistreatment.

Correct Answer is ["B","E","F","G"]

Explanation

After the nurse witnesses a preoperative client signing the surgical consent form, the nurse signs the form as a witness. Which is the legal implication of the nurse's signature on the client's surgical consent form? Select all that apply.

The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?

The nurse is caring for a client who has a history of experiencing delusions. The client describes singing in a concert in the afternoon for thousands of people. Which action should the nurse take?

A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. Which resource is most important in designing this program?

Exhibits

The nurse is reviewing the client's data. Which of the following findings should the nurse report to the primary health care provider immediately? Select all that apply.