The RN is caring for James, an elderly man, in his home. The client’s son, Brad, is visiting and he plans to take James to the bank so that he can sign a Power of Attorney (POA) for his finances over to Brad. James tells the nurse that he is not ready for his son to take over as POA, but he doesn’t want to make him angry.
What should the nurse do next?

Assure the patient that his son has his best interest in mind.

The nurse has no accountability for this situation since it is not a clinical issue.

Notify the primary care physician that the patient can no longer care for himself.

Contact the department of aging to report suspected financial abuse.

Answer and Explanation

The Correct Answer is D

The nurse has a duty to protect the patient’s rights and well-being, and to report any signs of abuse or neglect. Financial abuse is defined as someone illegally or improperly using an elder’s money or belongings for their own personal use. It is a common form of elder abuse and can have serious consequences for the victim’s physical and mental health.

The nurse should not assume that the son has the patient’s best interest in mind (choice A), as this may not be the case.

The nurse should not ignore the situation or dismiss it as a non-clinical issue (choice B), as this would violate the nurse’s ethical and legal obligations. The nurse should not notify the primary care physician that the patient can no longer care for himself (choice C), as this may not be true and may infringe on the patient’s autonomy and dignity.

The nurse should respect the patient’s wishes and help him to exercise his rights and choices.

The nurse should also provide support and resources to the patient, such as counselling, legal aid, or social services.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is A

Explanation

Fluid volume excess is wrong because appendicitis does not cause fluid retention or overload. It may cause fluid loss due to vomiting, fever, or rupture of the appendix. Therefore, a more appropriate nursing diagnosis would be the risk for deficient fluid volume.

Choice B. Risk for infection is correct because appendicitis is an inflammatory condition that can lead to bacterial infection, especially if the appendix ruptures and causes peritonitis or abscess formation.

Choice C. Ineffective thermoregulation is correct because appendicitis can cause fever due to inflammation and infection.

Choice D. Pain is correct because appendicitis causes acute abdominal pain that usually starts in the periumbilical area and then localizes to the right lower quadrant. The pain may be accompanied by nausea, vomiting, and rebound tenderness.

A. The lack of healing of the stump. B. Ineffective control of the client’s pain. C. The removal of the wrong arm. D. The client being mildly sedated.

Correct Answer is C

Explanation

This action is intended to prevent a sentinel event, which is a patient safety event that results in death, permanent harm, or severe temporary harm. A sentinel event is a serious adverse event that signals the need for immediate investigation and response. Removing the wrong arm would be a devastating and irreversible outcome for the patient and the health care provider.

Choice A is wrong because the lack of healing of the stump is not a sentinel event. It is a possible complication of amputation that may be related to the natural course of the patient’s illness or underlying condition.

Choice B is wrong because ineffective control of the client’s pain is not a sentinel event. It is a quality of care issue that may affect the patient’s comfort and recovery, but it does not result in death, permanent harm, or severe temporary harm.

Choice D is wrong because the client being mildly sedated is not a sentinel event. It is a level of anesthesia that may be appropriate for some types of surgery, but it does not result in death, permanent harm, or severe temporary harm.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following nursing diagnoses would the nurse be LEAST likely to choose for a patient with appendicitis?

Correct Answer is A

Explanation

While preparing a client for surgery, the nurse marks the arm that is to be amputated and participates in a “time-out” procedure before the surgery begins. Which sentinel event is this action intended to prevent?

Correct Answer is C

Explanation

The nurse includes which of the following as an appropriately constructed goal statement for the client with COPD?

A nurse is reinforcing teaching with a client about healthful sleep habits. Which of the following statements should the nurse identify as an indication that the client needs further instructions?

An elderly client is hospitalized for the first time. Which of the following actions ensures the safety of the client? (Select all that apply).

A nurse is caring for a patient with a BMI of. Appropriate nursing interventions include:

The nurse identifies chronic pain as an appropriate nursing priority (or problem/diagnosis) for a client with fibromyalgia. Which manifestation did the client most likely report that caused the nurse to select this priority?

A nurse is reinforcing teaching with a client who has a new diagnosis of fibromyalgia. Which of the following information should the nurse include in the teaching?

A nurse is caring for a client with chronic fatigue syndrome. Which of the following criteria were used to assist in making this diagnosis? Select all that apply.

The RN performs an admission assessment and determines the client is a fall risk. What is a priority nursing intervention for this client?