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 A
Explanation
Choice A rationale
Informed consent is a dynamic and ongoing process, not a one-time event. A client has the autonomous right to refuse a procedure at any point, even after having previously signed a consent form. This right is based on the principle of client autonomy, which states that competent individuals have the right to make decisions about their own healthcare, including the right to withdraw consent at any time. The signed form simply documents that the discussion occurred; it does not nullify the client's right to change their mind.
Choice B rationale
The ability to write is not a prerequisite for providing informed consent. A client who is unable to write can still provide verbal consent, and this is typically documented by a witness. The key components of informed consent are the client's understanding of the procedure and their voluntary agreement. As long as the client can comprehend the information and communicate their decision, they are considered capable of providing consent. A mark or a signature from a witnessed verbal consent can be used to formalize the documentation process.
Choice C rationale
A client who is blind is fully capable of providing informed consent as long as they can understand the information being presented. The nurse or healthcare provider must ensure that the information is communicated in a manner the client can comprehend, which may include reading the consent form aloud and answering any questions. The visual impairment does not compromise the client's cognitive ability to make decisions about their own healthcare, and therefore, a guardian is not required for this reason.
Choice D rationale
While a nurse can and often does clarify information, the primary responsibility for explaining surgical risks and benefits to a client lies with the surgeon or the healthcare provider performing the procedure. The physician must provide a comprehensive explanation of the procedure, including all potential risks, benefits, and alternatives, to ensure the client is fully informed. The nurse's role is to act as a witness to the signature and to ensure the client has had their questions answered, and to notify the provider if they have new questions or concerns. *.
Correct Answer is A
Explanation
Choice A rationale
Metformin extended-release tablets are designed with a special matrix that releases the medication gradually over time. Crushing or chewing the tablet would destroy this matrix, leading to an immediate and potentially unsafe release of the entire dose. This could cause a sudden drop in blood glucose and increase the risk of adverse gastrointestinal side effects.
Choice B rationale
Metformin is typically recommended to be taken with the evening meal to minimize gastrointestinal side effects such as nausea and diarrhea, which are common when starting the medication. Taking it in the morning on an empty stomach could increase the severity of these adverse effects due to the rapid concentration increase in the gastrointestinal tract.
Choice C rationale
Metformin is not associated with weight gain; in fact, it is often associated with a small amount of weight loss. This is due to its effect on reducing appetite and its ability to improve insulin sensitivity, which can help regulate metabolism and prevent the weight gain often seen with other diabetes medications.
Choice D rationale
Metformin is best taken with a meal to enhance its absorption and to mitigate common gastrointestinal side effects. Taking it on an empty stomach can increase the likelihood and severity of adverse effects like nausea, vomiting, and diarrhea because the medication can directly irritate the gastrointestinal mucosa
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