A client reports pain worsening in their right forearm, rating the pain as 7 on a scale of 0 to 10. The client also states their right hand is "tingly.”. The client is able to move their fingers.

The client is avoiding eye contact with staff and is more withdrawn.

The client's adult child is at the bedside.

The client appears drowsy and less alert, but is oriented to person, place, time, and situation.

The client's apical pulse is regular, and their lungs are clear to auscultation.

A report is given to the operating room nurse, and the client is en route to the surgical suite via gurney for repair of a right radial fracture.

Encourage the client to ambulate to the bathroom.

Check the client's peripheral pulses and capillary refill.

Elevate the client's arm above the level of the heart.

Administer a sedative to help the client relax.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Encouraging the client to ambulate to the bathroom would be inappropriate and potentially harmful. The client is experiencing worsening pain, tingling, and is on a gurney en route to surgery for a fractured radius. Ambulation could exacerbate the injury, increase pain, and risk further complications. Mobility should be restricted until the fracture is stabilized and the client is post-operative.

Choice B rationale

This is the correct action as it assesses for potential complications of compartment syndrome, a critical and urgent condition. The worsening pain and tingling are classic symptoms. Compartment syndrome occurs when pressure builds within the fascial compartments, compromising circulation. A loss of peripheral pulses and delayed capillary refill are late signs of impaired circulation and are key indicators for this limb-threatening emergency.

Choice C rationale

Elevating the arm above the heart would decrease arterial blood flow to the injured extremity, which could worsen tissue perfusion and potentially lead to ischemia. For a client with a suspected circulatory compromise, such as with compartment syndrome, the arm should be kept at the level of the heart to maintain adequate blood flow.

Choice D rationale

Administering a sedative could mask the client's symptoms, particularly the level of pain and changes in mental status, which are crucial indicators of their deteriorating condition. The client's pain is a vital sign that needs to be continuously monitored, and sedation would hinder the nurse's ability to accurately assess for changes in their neurovascular status. .

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Correct Answer is []

Explanation

Condition: Elder maltreatment 2 actions: Initiate a referral to adult protective services; Administer prescribed pain medication 2 parameters: Frequency and severity of bruises; Nutritional intake and weight

Rationale for correct condition The client’s physical signs (multiple bruises in various stages, unclean appearance), social indicators (dependency, financial control, food insecurity), and behavioral changes in the presence of the caregiver strongly suggest elder abuse. Elder maltreatment includes physical, emotional, financial, and neglectful harm. An 82-year-old with a BMI of 18.3 shows undernutrition. His improved demeanor away from the child reflects psychological coercion. Bruises in different stages may indicate repeated trauma over time.

Rationale for correct actions Referral to adult protective services ensures legal and social intervention and facilitates multidisciplinary evaluation for safety. Reporting is mandated and protects the client from further harm. Administering pain medication addresses acute injury (fracture of right radius) and helps restore comfort. Effective pain management is crucial for mobility and assessment of additional injuries.

Rationale for correct parameters Monitoring bruising patterns helps identify ongoing abuse and quantify recovery or new trauma. Repeated injuries in various healing stages are hallmark signs. Nutritional intake and weight reflect neglect; insufficient food intake leads to weight loss and reduced immune function. Tracking BMI and calorie intake can guide long-term recovery and support.

Rationale for incorrect conditions Osteoporosis-related fracture would more likely occur with minimal trauma and does not explain social neglect or emotional signs. Accidental fall may be plausible but lacks explanation for systemic neglect and coercion. Peripheral neuropathy doesn’t explain acute arm pain or psychosocial signs of neglect.

Rationale for incorrect actions Encouraging activity is inappropriate during acute fracture recovery and potential abuse. Bone density scans assess fragility but don’t address safety risks. Nutritional supplements may help but don’t resolve underlying maltreatment or acute injury.

Rationale for incorrect parameters Bone density is not immediately relevant and doesn't reflect maltreatment. Blood pressure fluctuations are not present and don’t indicate abuse. Grip strength cannot be assessed accurately with an arm fracture and isn't useful for abuse evaluation.

Take-home points • Elder maltreatment includes physical harm, neglect, emotional abuse, and financial exploitation • Victims may show improved responsiveness when abuser is absent • Multidisciplinary intervention via adult protective services is critical • Differentiation from accidental injury ensures proper protection and care

A. The flat line between the QRS complex and the T wave. B. The peak of the R wave. C. The beginning of the P wave. D. The interval between the S wave and the T wave.

Correct Answer is A

Explanation

Choice A rationale

The ST segment represents the time from the end of ventricular depolarization to the beginning of ventricular repolarization. It is identified as the flat baseline following the QRS complex and preceding the T wave. This segment is isoelectric, meaning it's at the same level as the PR segment, and any deviation can indicate myocardial ischemia or injury.

Choice B rationale

The peak of the R wave represents the peak of ventricular depolarization. It signifies the moment of maximum electrical activity in the ventricles, as the impulse spreads through the ventricular walls. It is a critical point in the QRS complex, but it is not the location of the ST segment.

Choice C rationale

The beginning of the P wave marks the onset of atrial depolarization. This electrical event represents the contraction of the atria as they pump blood into the ventricles. The P wave is the first deflection in the cardiac cycle and occurs well before the QRS complex and the ST segment.

Choice D rationale

The interval between the S wave and the T wave is not a standard electrocardiographic term. The correct terminology is the ST segment, which is a segment, not an interval, and it specifically follows the S wave and precedes the T wave. An interval would typically include a wave, like the QT interval. *.

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Naxlex Comprehensive Predictor Exams

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

Correct Answer is []

Explanation

A nurse is reviewing the ECG tracing strip of a client who is receiving telemetry monitoring. The nurse should locate the S-T segment at which of the following locations on the electrocardiographic waveform.

Correct Answer is A

Explanation

A nurse is caring for a client who is postpartum and expresses concern about how her preschool-age son will react to having a baby sister. Which of the following strategies should the nurse suggest?

A nurse is caring for a client who has schizophrenia. The client states, "The voices in my head are driving me crazy.”. Which of the following Questions should the nurse ask?

A nurse is teaching a client who is at 20 weeks of gestation about how to manage heartburn. Which of the following instructions should the nurse include.

A nurse is planning care for a client who is at 32 weeks of gestation and has severe preeclampsia. Which of the following actions should the nurse plan to take?

A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take first?

A nurse is caring for four children in an emergency department. Which of the following clients should the nurse assess first?

A nurse is assessing a client who has schizophrenia prior to administering the client's next dose of clozapine. Which of the following findings should the nurse report to the provider?

A nurse is caring for a client following an involuntary admission to an acute mental health facility. The client states, "I'm afraid they will give me drugs that put me to sleep.”. Which of the following statements should the nurse make?