Try Naxlex NCLEX-RN (Free-Trial)

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

Answer and Explanation

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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A rationale

Administering a suppository is considered a medication administration task, which requires a licensed nurse to perform. This task involves critical thinking and a solid understanding of anatomy, physiology, and pharmacology, as well as the potential for adverse reactions. Therefore, this cannot be delegated to an assistive personnel (AP), whose scope of practice does not include medication administration.

Choice B rationale

Providing home care instructions is part of client education, which is a key responsibility of a licensed nurse. This task requires a thorough understanding of the client's condition, treatment plan, and the ability to assess their learning needs. An AP is not trained to assess, plan, or implement teaching plans for clients, so this task is outside their scope of practice.

Choice C rationale

Suctioning a newly inserted tracheostomy is a skilled and invasive procedure that carries a high risk of complications, such as hypoxemia, trauma, or infection. This procedure requires a nurse's professional judgment and a clear understanding of sterile technique. The AP's role is to provide basic care, not to perform such complex and high-risk procedures.

Choice D rationale

Performing rescue breathing, or cardiopulmonary resuscitation (CPR), is an emergency procedure that falls within the scope of an AP's training. All healthcare workers, including APs, are required to have a basic life support certification. In a medical emergency, every staff member is expected to perform basic life-saving measures, such as rescue breathing, to prevent further client harm. *.

A. The flat line between the QRS complex and the T wave. B. The peak of the R wave. C. The beginning of the P wave. D. The interval between the S wave and the T wave.

Correct Answer is A

Explanation

Choice A rationale

The ST segment represents the time from the end of ventricular depolarization to the beginning of ventricular repolarization. It is identified as the flat baseline following the QRS complex and preceding the T wave. This segment is isoelectric, meaning it's at the same level as the PR segment, and any deviation can indicate myocardial ischemia or injury.

Choice B rationale

The peak of the R wave represents the peak of ventricular depolarization. It signifies the moment of maximum electrical activity in the ventricles, as the impulse spreads through the ventricular walls. It is a critical point in the QRS complex, but it is not the location of the ST segment.

Choice C rationale

The beginning of the P wave marks the onset of atrial depolarization. This electrical event represents the contraction of the atria as they pump blood into the ventricles. The P wave is the first deflection in the cardiac cycle and occurs well before the QRS complex and the ST segment.

Choice D rationale

The interval between the S wave and the T wave is not a standard electrocardiographic term. The correct terminology is the ST segment, which is a segment, not an interval, and it specifically follows the S wave and precedes the T wave. An interval would typically include a wave, like the QT interval. *.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a group of clients and identifying what tasks she can delegate to an assistive personnel (AP). Which of the following tasks should the nurse delegate to an AP?

Correct Answer is D

Explanation

A nurse is reviewing the ECG tracing strip of a client who is receiving telemetry monitoring. The nurse should locate the S-T segment at which of the following locations on the electrocardiographic waveform.

Correct Answer is A

Explanation

A nurse is assessing a client who is taking losartan. Which of the following findings should the nurse identify as an adverse effect of this medication?

A nurse is planning assignments for the upcoming shift. Which of the following tasks should the nurse delegate to an assistive personnel?

A nurse is teaching a client who has a new prescription for metformin extended release tablets. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is replacing the dressing for a client who is postoperative following thoracic surgery. When assessing the surgical wound, which of the following findings should the nurse identify as an indication of infection?

A nurse is assessing a client who has schizophrenia prior to administering the client's next dose of clozapine. Which of the following findings should the nurse report to the provider?

A nurse is teaching a client who is at 20 weeks of gestation about how to manage heartburn. Which of the following instructions should the nurse include.

A charge nurse observes smoke coming from a trash receptacle in the unit's waiting room. Which of the following actions should the nurse take first?

A nurse is caring for a client who has a new prescription for spironolactone and reports that they forgot to tell the provider that they take over-the-counter supplements. The nurse should instruct the client to avoid which of the following supplements?