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
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. .
Correct Answer is A
Explanation
Choice A rationale
This 12-year-old child with cystic fibrosis and difficulty clearing secretions is the priority. Cystic fibrosis causes thick mucus to accumulate in the lungs, leading to airway obstruction. Inability to clear these secretions indicates a potential acute respiratory crisis, which can rapidly progress to respiratory failure. This is a life-threatening airway and breathing emergency requiring immediate assessment and intervention to prevent respiratory compromise.
Choice B rationale
A 3-year-old with an atrial septal defect and a heart rate of 120/min is a non-acute finding. A heart rate of 120/min is within the normal range for a toddler (90-140/min) and is a common physiological response in a child with a heart defect to maintain cardiac output. This child is stable and does not present with an immediate life-threatening condition.
Choice C rationale
A 2-year-old with diarrhea and abdominal pain is a non-acute finding. While these symptoms require attention, they are common in toddlers and do not typically represent an immediate life-threatening emergency unless accompanied by signs of severe dehydration or septic shock. Other children with respiratory issues take priority due to the higher potential for rapid decompensation.
Choice D rationale
A 5-year-old with type 1 diabetes mellitus and a blood sugar of 150 mg/dL is stable. A blood sugar of 150 mg/dL is within a safe, controlled range for a child with type 1 diabetes, which is typically 80-180 mg/dL. This child does not require immediate intervention as their blood glucose is not indicative of hypo- or hyperglycemia crises. .
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