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.
Client’s report of lack of access to bank accounts
Client’s avoidance of eye contact
Client’s report of weight loss
Numerous bruises in various stages of healing
Client’s report of lack of food in the house
Client’s strong body odor
Right arm fracture
Correct Answer : A,D,E,F,G
The nurse should plan to include the following five findings in the report to the social worker, as they raise significant concern for elder maltreatment:
Findings to Include
• A. Client’s report of lack of access to bank accounts → Suggests financial exploitation, especially since the client gives income to the adult child but cannot access funds.
• D. Numerous bruises in various stages of healing → Strong indicator of physical maltreatment, possibly repeated trauma over time.
• E. Client’s report of lack of food in the house → Points to neglect, particularly in meeting basic nutritional needs.
• F. Client’s strong body odor → Suggests neglect in hygiene and personal care.
• G. Right arm fracture → A confirmed injury that, in context with other findings, may not align with a simple accidental fall.
Findings Not Prioritized for Reporting
• B. Client’s avoidance of eye contact → May reflect fear or discomfort, but is not specific enough to confirm maltreatment.
• C. Client’s report of weight loss → While potentially concerning, it wasn’t documented in the case and lacks supporting data like previous weight or timeframe.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Postterm pregnancy, defined as a gestation extending beyond 42 weeks, is not a contraindication for misoprostol. In fact, it is a common indication for labor induction, as the placenta may begin to deteriorate, increasing the risk of fetal distress and meconium aspiration. Misoprostol, a prostaglandin E1 analog, helps ripen the cervix and stimulate uterine contractions. This pharmacologic action is beneficial in initiating labor in postterm pregnancies.
Choice B rationale
Transverse fetal lie is an obstetrical position where the fetus is lying sideways across the uterus. This position poses a significant risk of complications during vaginal birth, including uterine rupture and umbilical cord prolapse. Therefore, any attempt to induce labor with a medication like misoprostol is contraindicated. Cesarean delivery is typically the preferred method of delivery in cases of persistent transverse lie to ensure a safe delivery for both mother and fetus.
Choice C rationale
Intrauterine growth restriction (IUGR) is a condition where a fetus is smaller than expected for gestational age. It is not a contraindication for misoprostol. Often, IUGR is an indication for labor induction to prevent further fetal compromise. Misoprostol is a commonly used medication for this purpose, as it helps to initiate cervical ripening and uterine contractions, which can lead to a successful vaginal delivery.
Choice D rationale
A history of a cesarean section is a significant contraindication for misoprostol because it substantially increases the risk of uterine rupture. Misoprostol causes potent uterine contractions that can place undue stress on the uterine scar from the previous surgery. The risk of rupture is a life-threatening complication for both the mother and the fetus. Therefore, other methods of labor induction or a planned repeat cesarean section are often considered. *.
Correct Answer is A
Explanation
Choice A rationale
Spina bifida is associated with a high incidence of latex allergy due to repeated surgical procedures and catheterizations. There is a documented cross-reactivity between latex proteins and certain food proteins, particularly those found in bananas, avocados, kiwis, and chestnuts. These foods share similar antigenic determinants.
Choice B rationale
Strawberries are not typically associated with latex cross-reactivity. While they can cause allergic reactions in some individuals, the proteins responsible for these allergies do not share the same antigenic structures as those found in natural rubber latex. Therefore, a latex allergy does not necessarily predict a strawberry allergy.
Choice C rationale
Almonds are a tree nut, and while tree nut allergies are common, they are not typically linked to latex cross-reactivity. The allergenic proteins in almonds, such as the major protein Amandin, are structurally different from the proteins found in natural rubber latex, minimizing the risk of a cross-reaction.
Choice D rationale
Hazelnuts, like almonds, are a type of tree nut and are not generally known for cross-reactivity with latex. The proteins that trigger hazelnut allergies do not share significant homology with the proteins in natural rubber latex, so there is no established correlation between a latex allergy and a hazelnut allergy. .
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