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 C
Explanation
Choice A rationale
Drowsiness is a symptom of hypothyroidism, not hyperthyroidism (thyrotoxicosis). Levothyroxine is a synthetic thyroid hormone used to treat hypothyroidism. An overdose or excessive dose of this medication would lead to symptoms of hyperthyroidism, which is the opposite of drowsiness. Instead, clients would likely experience increased energy levels, anxiety, or insomnia.
Choice B rationale
Weight gain is a classic symptom of hypothyroidism, not thyrotoxicosis. When the body's metabolism slows down due to insufficient thyroid hormone, the client may gain weight. A client experiencing thyrotoxicosis from an excessive dose of levothyroxine would typically exhibit a hypermetabolic state, which often leads to unintended weight loss despite an increased appetite.
Choice C rationale
A fever is a sign of an accelerated metabolic rate, which is a key feature of thyrotoxicosis. When thyroid hormone levels become excessively high, the body's basal metabolic rate increases significantly, causing an increase in body temperature. This can manifest as a low-grade fever or even a significant fever in severe cases, requiring immediate medical attention.
Choice D rationale
Bradycardia, or a slow heart rate, is a symptom of hypothyroidism. The heart rate slows down as the body's overall metabolic processes decrease. Thyrotoxicosis is characterized by a rapid heart rate, known as tachycardia. This is due to the excessive stimulation of the cardiovascular system by high levels of thyroid hormone. A normal heart rate is typically between 60 and 100 beats per minute. .
Correct Answer is D
Explanation
Choice A rationale
Scant lochia rubra with a few small clots is a normal finding at 2 days postpartum. Lochia rubra, which is dark red discharge, is expected during the first 3-4 days. Scant bleeding and small clots are considered normal and indicate the uterine healing process is progressing appropriately. Excessive bleeding or large clots would be cause for concern.
Choice B rationale
Bilateral ankle edema is a common and expected finding at 2 days postpartum. This is due to the mobilization of fluid retained during pregnancy and the effects of gravity. While it should be monitored, it typically resolves on its own. The nurse should assess for other signs of a more serious condition, such as unilateral leg swelling, pain, or redness, which could indicate a deep vein thrombosis.
Choice C rationale
A urine output of 2,500 mL/day is within the expected range for a postpartum client. Diuresis is a normal physiological process during the first few days after birth, as the body eliminates the excess fluid volume accumulated during pregnancy. Urine output typically ranges from 2,000 to 3,000 mL/day, indicating adequate kidney function and fluid mobilization.
Choice D rationale
Deep-tendon reflexes of 4+ are a hyperreflexic finding that can indicate a neurological complication, such as preeclampsia. Normal deep-tendon reflexes are typically 1+ to 2+. Hyperreflexia is a sign of central nervous system irritability and can precede seizure activity, making it a critical finding that requires immediate reporting to the provider for further assessment and intervention. .
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