Patient Data
The nurse reviews the findings in the history and physical.
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The nurse recognizes that
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A","dropdown-group-3":"C"}
Pressure injuries: These can indicate neglect or inadequate care, as they often develop from prolonged periods of immobility or poor hygiene.
Poor hygiene: A foul odor and unclean environment, along with a lack of clothing, can be signs of neglect or mistreatment.
Malnutrition: The client's low weight (98 lb or 44.5 kg) and a lack of appropriate nutrition could indicate inadequate care and potential mistreatment, contributing to overall poor health and well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Fluid replacement is crucial to prevent dehydration and maintain electrolyte balance, which is vital in clients with severe ulcerative colitis and after surgery.
B. Turning the client is important to prevent pressure ulcers but is not as immediately critical as fluid balance.
C. Recording wound drainage is necessary but secondary to ensuring the client’s fluid and electrolyte status.
D. Assessing skin condition is important but fluid balance takes priority in this scenario.
Correct Answer is D
Explanation
A. Agreeing with the delusions can reinforce the false beliefs and is not an effective therapeutic approach.
B. Disagreeing and setting limits may escalate the client's anxiety or agitation and does not address the delusion in a therapeutic manner.
C. While informing the provider is important, the immediate action should focus on therapeutic communication with the client.
D. Presenting a personal perception of reality in a non-confrontational manner helps the client to gently challenge their delusion and encourages a more grounded conversation.
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