Which assessment finding would be considered normal in an elderly client?

Decreased flexibility.

Pain when standing.

Swelling of the ankles.

Urinary incontinence.

Answer and Explanation

The Correct Answer is A

Decreased flexibility is a normal age- related change that occurs in the elderly due to loss of elasticity in the ligaments and tendons.
Some possible explanations for the other choices are:
Choice B. Pain when standing. Pain when standing is not a normal finding and could indicate arthritis, osteoporosis, or injury.
Choice C. Swelling of the ankles. Swelling of the ankles is not a normal finding and could indicate heart failure, kidney disease, or venous insufficiency.
Choice D. Urinary incontinence. Urinary incontinence is not a normal finding and could indicate urinary tract infection, prostate enlargement, or neurological impairment.

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Correct Answer is ["A","B"]

Explanation

Increased heart rate and decreased blood pressure are common signs of dehydration, as the body tries to compensate for the fluid loss by increasing the heart rate and lowering the blood pressure.

Choice C is wrong because increased temperature is not a typical symptom of dehydration, although it can be a cause of it.

Choice D is wrong because hypoactive muscle responses are not related to dehydration, but rather to neurological or muscular disorders.

Choice E is wrong because alert and oriented is the normal mental status for most people, and dehydration can cause confusion and disorientation in severe cases.

Normal ranges for heart rate and blood pressure vary depending on age, gender, physical activity, and other factors, but generally they are:

Heart rate: 60 to 100 beats per minute for adults
Blood pressure: less than 120/80 mmHg for adults

A. The nurse establishes rapport with the client in an inpatient psychiatric setting. B. The nurse documents accurately and honestly in the electronic health record. C. The nurse refuses to care for someone who reminds her of a family member after interviewing the client upon admission. D. The nurse refers to the policy of the inpatient psychiatric setting when uncertain of a standard of care.

Correct Answer is C

Explanation

The nurse refuses to care for someone who reminds her of a family member after interviewing the client upon admission. This action is not appropriate in the prevention of liability because it violates the client’s right to receive care and may be considered as discrimination or abandonment. The nurse has a duty to provide care to all clients regardless of their personal feelings or preferences.

Choice A is wrong because establishing rapport with the client in an inpatient psychiatric setting is an appropriate action to prevent liability. It helps to build trust and communication between the nurse and the client and reduces the risk of misunderstanding or conflict.

Choice B is wrong because documenting accurately and honestly in the electronic health record is an appropriate action to prevent liability. It provides evidence of the care provided, the client’s condition and response, and any incidents or complications that occurred.

Choice D is wrong because referring to the policy of the inpatient psychiatric setting when uncertain of a standard of care is an appropriate action to prevent liability. It helps the nurse to follow the best practices and guidelines for providing safe and effective care to the client.

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Which assessment finding would be considered normal in an elderly client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A middle-aged adult client with nausea and vomiting for three days presents to the emergency room. Which findings should the nurse expect to assess in a client diagnosed with dehydration? Select all that apply.

Correct Answer is ["A","B"]

Explanation

A nurse takes actions to avoid liability when caring for a client with a psychiatric disorder. Which action is not appropriate in the prevention of liability?

Correct Answer is C

Explanation

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