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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.

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Correct Answer is B

Explanation

Choice A rationale

Visual disturbances are a less common side effect of risperidone and are not typically considered a priority finding. While they can be a nuisance for the client, they do not pose an immediate threat to the client's life. Other side effects require more immediate attention and intervention from the healthcare provider.

Choice B rationale

Risperidone can cause cardiac side effects such as QT prolongation, which can lead to life-threatening arrhythmias like Torsades de pointes. An irregular pulse is a critical finding that could indicate an underlying cardiac issue and requires immediate evaluation. This is a priority finding for the nurse to report to the provider.

Choice C rationale

Constipation is a common side effect of risperidone due to its anticholinergic properties. While it can cause discomfort, it is not an immediate life-threatening condition. The nurse should address this by encouraging fluid and fiber intake and possibly discussing a stool softener with the provider, but it is not the highest priority.

Choice D rationale

Dry mouth is a common and relatively benign side effect of risperidone. While it can cause discomfort and increase the risk of dental caries, it is not an urgent or life-threatening condition. The nurse can advise the client on strategies to manage this symptom, such as using sugar-free candies or chewing gum. *.

A. During this test, I must not eat or drink anything. B. This test will tell me if my baby has a genetic problem. C. During this test, I will push a button if my baby moves. D. I will get oxytocin during this test.

Correct Answer is C

Explanation

Choice A rationale

A nonstress test (NST) does not require the client to fast. The client can eat and drink normally, and sometimes a sugary beverage is even encouraged to stimulate fetal movement, as the test aims to record fetal heart rate accelerations in response to these movements.

Choice B rationale

The nonstress test is a screening tool used to assess fetal well-being by measuring the fetal heart rate's response to fetal movement. It does not provide information about genetic problems, which are typically identified through genetic testing or prenatal diagnostic procedures such as amniocentesis.

Choice C rationale

A key component of the nonstress test involves the mother noting fetal movements. The client is given a marker, often a button, to press each time she feels the baby move. This action correlates the mother's perception of movement with the fetal heart rate accelerations recorded on the monitor.

Choice D rationale

Oxytocin is not administered during a nonstress test. The purpose of this test is to assess the baby's baseline heart rate and accelerations without external stimulation. Oxytocin is used in a contraction stress test, which is a different procedure to evaluate how the baby handles uterine contractions. *.

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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 assessing a client who has schizophrenia and is taking risperidone. Which of the following adverse effects of the medication is the priority finding for the nurse to report to the provider?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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