A client's adult child left the facility to go home and get the client's prescribed medications.

The client is visibly more relaxed and now speaking more openly to staff with improved eye contact.

The client reports they have lived with their adult child for the past several months due to their inability to care for themselves without assistance.

The client states their adult child "gets frustrated with me, but I understand why.

I move so slow and need help with everything.”. The client states they give their retirement income to their adult child to pay for their prescribed medication and household expenses, but they have no access to the bank account.

The client states their adult child makes "a few meals a week" and that there is little food in the house.

What should be the nurse's priority action based on this information?

Report suspected elder abuse to the appropriate authorities.

Ask the client's adult child about the client's financial situation.

Educate the client's adult child about the importance of nutrition.

Encourage the client to discuss their frustrations with their adult child.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Based on the client's statements, there is strong evidence of neglect and potential exploitation. Neglect is indicated by the inadequate food supply and minimal meal preparation. Financial exploitation is suggested by the client's lack of access to their retirement income, despite it being used for their care. This situation poses a serious risk to the client's well-being, triggering the nurse's ethical and legal duty to report suspected elder abuse to the appropriate authorities.

Choice B rationale

While gathering more information is often a good practice, directly questioning the adult child about financial matters could escalate the situation and potentially put the client at further risk. The primary responsibility of the nurse in this scenario is to ensure the client's safety, and the existing information is sufficient to warrant a report. The client has already provided a detailed account of the financial arrangement and their lack of access to funds, which is a key indicator of exploitation.

Choice C rationale

Educating the adult child about nutrition, while potentially helpful in some circumstances, does not address the immediate and serious issues of neglect and financial exploitation. The client's safety is the priority. Focusing solely on education ignores the broader pattern of abuse and the client's vulnerability, which requires a more direct and protective intervention.

Choice D rationale

Encouraging the client to speak with their adult child may place them in a more vulnerable position and could increase the risk of retaliation or further neglect. The client has already expressed an understanding of their adult child's frustration, and this approach fails to address the power imbalance and exploitative nature of the relationship. It is not an appropriate or safe intervention in a situation of suspected abuse. *.

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Correct Answer is B

Explanation

Choice A rationale

Administering a vasoconstrictor is a potential intervention for shock but it is not the first action. The client's hypotension and tachycardia are indicative of hypovolemic shock due to profuse vomiting, leading to fluid loss. The body's initial compensatory mechanism involves vasoconstriction to maintain blood pressure, so further constriction without addressing the volume deficit can worsen tissue perfusion.

Choice B rationale

The client is exhibiting signs of hypovolemic shock, including a low blood pressure of 86/58 mmHg, a high pulse of 114/min, and a high respiratory rate of 27/min. These are physiological compensations for reduced circulating blood volume. Increasing the intravenous infusion rate directly addresses the primary problem by rapidly replacing lost fluid volume, thereby increasing preload, stroke volume, cardiac output, and ultimately, blood pressure.

Choice C rationale

Elevating the client's feet can temporarily increase venous return to the heart and improve blood pressure. However, this is a passive measure that does not address the underlying fluid deficit causing the hypovolemic shock. It is a helpful adjunctive action but is not the definitive first-line intervention required to correct the circulatory collapse in this scenario.

Choice D rationale

Initiating oxygen therapy is a supportive measure for shock because it helps improve tissue oxygenation, which is compromised due to poor perfusion. While beneficial, it does not correct the root cause of the shock, which is the lack of circulating fluid volume. The most immediate and life-saving intervention is to restore fluid volume to improve cardiac output and blood pressure

A. I will wear a color-coded wristband so everyone knows I am at risk of falling. B. I will have to wear a restraint around my waist when I am sitting up in a chair. C. I should store my personal items all together on the shelf in my bathroom. D. I should keep the overhead lights on at all times while I am here.

Correct Answer is A

Explanation

Choice A rationale

A color-coded wristband, such as yellow, serves as a visual cue to all healthcare staff that a client has an increased risk of falling. This system promotes a universal understanding of the client's needs, allowing all members of the care team to implement appropriate fall prevention measures proactively and consistently, such as providing assistance with ambulation or frequent rounding.

Choice B rationale

The use of physical restraints, such as a restraint around the waist, is a last resort and requires a provider's order. It is not considered a primary fall prevention strategy. Restraints can increase a client's risk of injury and are associated with negative outcomes, including agitation, skin breakdown, and loss of muscle mass. Fall prevention strategies focus on proactive, non-restrictive interventions.

Choice C rationale

Storing personal items in a bathroom, especially on a high shelf, creates a significant fall hazard. The client may overreach or stand on a stool to retrieve items, increasing their risk of losing balance. To prevent falls, all personal items should be kept within easy reach of the client, such as on the bedside table, to minimize unnecessary movement.

Choice D rationale

While keeping some light on is helpful, having overhead lights on at all times can cause glare and create shadows that distort depth perception. This can make it difficult for a client with vision impairments to see potential obstacles. A low-level nightlight is a safer alternative for nighttime visibility, as it minimizes glare and helps maintain a normal sleep-wake cycle. *.

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse at an acute care facility is teaching a client about fall risk prevention strategies for use during their stay at the facility. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is preparing to administer medication to a client. Which of the following identifiers should the nurse use to identify the client?

A nurse is caring for a client who is postoperative following a mitral balloon valvuloplasty. Which of the following areas should the nurse auscultate to assess the mitral area of the heart?

A nurse in an emergency department (ED) is assessing a preschooler who has a fractured arm. For which of the following should the nurse further investigate as a warning sign of child maltreatment?

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

A nurse is inserting a short peripheral IV catheter for a client who requires IV fluids. Which of the following actions should the nurse take?

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 community health nurse is providing education to a group of older adults about immunizations. Which of the following immunizations should the nurse recommend?

A client presents to the clinic for a postoperative follow-up following surgical repair of a fractured radius. The client reports their adult child prepares two meals a day for them to eat. The client's weight is 55.9 kg (123 Ib) and height is 175 cm (69 in). What is the client's BMI?