A nurse in an emergency department is caring for a client. Nurses' Notes.
1200:.
Client is an 82-year-old male who presents with his adult child for evaluation of right arm pain after a fall. Client noted to have several superficial abrasions on right forearm and elbow. Also has numerous bruises in various stages of healing on arms and upper chest. Client rates pain in right lower forearm an 8 on a 0 to 10 pain scale and is not moving the arm.
1210:.
Client noted to keep head down and makes limited eye contact. Speaks very softly and looks at adult child before answering interview questions. Has strong body odor and clothes are unclean. Client's adult child answers most questions. Client grimacing and guarding right arm.
Client weighed, is 56.2 kg (124 lb) and 175 cm (69 in) tall. BMI 18.3.
1230:.
Client's adult child left facility to go home and get the client’s prescribed medications. Client visibly more relaxed and now speaking more openly to staff with improved eye contact. Client reports that he has lived with his adult child for the past several.
Vital Signs. 1200:.
Temperature 36.7° C (98° F). Heart rate 96/min.
Blood pressure 142/96 mm Hg. Respiratory rate 16/min.
SpO2 97% on room air.
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.
ECG results.
Client's report of lack of food in home.
client's report of lack of access to bank accounts.
Clients avoidance of eye contact.
Clients report of weight loss.
Numerous bruises in various stages of healing.
Correct Answer : B,C,D,E,F
Answer is B, C, D, E, F. These are the findings that suggest possible elder abuse or neglect.
- B: Client’s report of lack of food in home. This may indicate neglect by the adult child who is supposed to provide adequate nutrition for the client.
- C: Client’s report of lack of access to bank accounts. This may indicate financial abuse by the adult child who is controlling the client’s money without his permission.
- D: Client’s avoidance of eye contact. This may indicate emotional abuse by the adult child who is intimidating or threatening the client.
- E: Client’s report of weight loss. This may indicate neglect by the adult child who is not meeting the client’s basic needs or physical abuse by the adult child who is causing bodily harm to the client.
- F: Numerous bruises in various stages of healing. This may indicate physical abuse by the adult child who is hitting or injuring the client.
A: ECG results. This is not a finding that suggests elder abuse or neglect. It is a diagnostic test that measures the electrical activity of the heart and can help detect cardiac problems. It does not provide information about the client’s social or emotional well-being.
Normal ranges for vital signs:.
- Temperature: 36.1°C to 37.2°C (97°F to 99°F).
- Heart rate: 60 to 100 beats per minute.
- Blood pressure: less than 120/80 mm Hg.
- Respiratory rate: 12 to 20 breaths per minute.
- SpO2: 95% to 100% on room air. Table for BMI categories:
|
BMI |
Weight Status |
|
Below 18.5 |
Underweight |
|
18.5 to 24.9 |
Normal |
|
25.0 to 29.9 |
Overweight |
|
30.0 and above |
Obese |
The client’s BMI is 18.3, which indicates he is underweight and may be malnourished or have a medical condition that causes weight loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D. Remind the client to use the incentive spirometer.
Choice A rationale:
Observing the position of the suspended weight is beyond the scope of practice for assistive personnel (AP). This task requires assessment skills to ensure proper alignment and functioning of the traction system, which is the responsibility of the nurse.
Choice B rationale:
Checking the client’s pedal pulse on the right leg involves assessment and clinical judgment to evaluate perfusion and detect potential complications such as impaired circulation. This is not a task that can be delegated to AP.
Choice C rationale:
Asking the client to describe her pain requires assessment and interpretation of subjective data, which falls under the nurse's scope of practice. Pain assessment is a critical nursing function.
Choice D rationale:
Reminding the client to use the incentive spirometer is a non-assessment task that involves reinforcing previously taught instructions. This is appropriate to delegate to assistive personnel, as it does not require clinical judgment.
Correct Answer is C
Explanation
Banana slices are soft, easy to chew, and can be picked up by the toddler’s fingers, which promotes independence in eating. According to the CDC, foods that toddlers should avoid include:
- Added sugars and no-calorie sweeteners, such as sugar-sweetened and diet drinks
- High-salt foods, such as canned foods, processed meats, frozen dinners, fast food, and junk food
- Unpasteurized juice, milk, yogurt, or cheese
- Foods that may cause choking, such as hard or crunchy foods, sticky foods, stringy cheese, and foods that are not cut up into small pieces
Choice A is wrong because popcorn is a choking hazard for toddlers.
It is hard, crunchy, and can get stuck in the airway. The NHS advises not to give whole nuts and peanuts to children under 5 years old.
Choice B is wrong because grapes are also a choking hazard for toddlers.
They are round, slippery, and can block the airway. The NHS recommends cutting grapes into quarters before giving them to young children.
Choice D is wrong because hot dogs are high in salt and can cause choking if not cut up into small pieces. The Extension warns against giving hot dogs to young toddlers.
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