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A nurse is caring for a newly admited older adult client.

Nurses' Notes

Day 1, 12:00:

Transferred to medical-surgical unit from emergency department (ED) for continued care following a closed reduction and immobilization of a fracture of the right arm. Accompanied by adult child.

Client in visibly soiled night clothes with multiple stains, including what appears to be dried blood. Hair, teeth, and fingernails unclean. Strong body odor noted. Bruising of various stages noted around upper arms, back, shoulders, and neck area.

Client is soft-spoken, speaks almost in a whisper, does not make eye contact with nurse.

Client looks at their child before answering the nurse's questions and, when asked how the injury occurred, mumbles "I don't know. Ask them." Client's child states, "He gets confused sometimes. I can answer your questions."

Which of the following interventions should the nurse recommend to include in the client's plan of care?

Select all that apply.

Tell the client's child that they will be reported for maltreatment of the client.

Ask the client's child to provide details regarding the client's fractured arm.

Discuss respite care options with the client's child.

Speak to the client privately.

Provide legal advice to the client regarding power of atorney.

Answer and Explanation

Correct Answer : B,C,D

The correct answers are b, c, and d.

a. It is not appropriate for the nurse to threaten the client's child with reporting for maltreatment without

further assessment and evidence.

b. Asking the client's child to provide details regarding the client's fractured arm will provide additional information about the client's injury and help the nurse assess the potential for abuse or neglect.

c. Discussing respite care options with the client's child may help alleviate any caregiver stress or burden, and ensure the client's continued care and safety.

d. Speaking to the client privately will help establish trust and rapport, and allow the client to disclose any concerns or issues that they may not feel comfortable sharing in front of their child.

e. Providing legal advice regarding power of atorney is not within the scope of nursing practice and should be referred to a legal professional. Additionally, the client's capacity to make decisions and appoint a power of atorney should be assessed before providing such advice.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Dementia is a condition characterized by a decline in cognitive function that aﬀects a person's ability to perform activities of daily living (ADLs). Memory loss is a common symptom of dementia, particularly in the early stages. Memory loss can disrupt a person's ability to carry out tasks they were previously able to do independently, such as dressing, bathing, and eating. Therefore, option A is the correct answer.

Option b, catatonia, is a condition characterized by a lack of movement or activity, which is not typically associated with dementia.

Option c, illusions, involve a misinterpretation of sensory information and may occur in some forms of dementia but are not a defining feature.

Option d, pressured speech, is a symptom commonly associated with mania or bipolar disorder but is not typically seen in dementia.

A. Have the client's partner sign an AMA form B. Discharge the client and notify the health care provider. C. Ask the partner to reiterate the consequences of leaving AMA to the client. D. Request the services of an interpreter to determine the client's wishes.

Correct Answer is D

Explanation

Effective communication with the client is crucial to understand their desires and provide appropriate care. When faced with a language barrier, it is important to use professional interpreter services to ensure accurate and clear communication. By requesting an interpreter, the nurse can obtain a clear understanding of the client's wishes and concerns regarding leaving AMA.

Without clear communication with the client, it is not appropriate to assume that the partner can make decisions on their behalf or sign an AMA form. It is important to directly ascertain the client's wishes.

Discharging the client without understanding their wishes and providing appropriate education or interventions could potentially put the client at risk. It is necessary to have a clear understanding of the client's desires before taking any action.

Asking the partner to reiterate the consequences of leaving AMA to the client: While educating the client and their partner about the consequences of leaving AMA is important, it is not sufficient in this situation. The nurse needs to directly communicate with the client to understand their wishes and concerns.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has dementia. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is caring for a client who speaks a different language than the nurse. The client's partner tells the nurse that the client would like to go home against medical advice (AMA). Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is assisting with monitoring a client who is receiving a unit of packed RBCs. Which of the following findings indicates the client is experiencing a hemolytic transfusion reaction?

A nurse is providing change-of-shift report for a client. Which of the following information should the nurse include in the report?

A nurse is assisting with the admission of an older adult client who has impaired mobility and is at risk for falls. Which of the following fall precautions should the nurse plan to implement first?

A nurse is collecting data from a client who has a long leg cast on his left leg. Which of the following findings is the priority?

A nurse is participating in an interprofessional client care conference for a client who has experienced a stroke. The nurse should identify that which of the following client care issues requires reporting to the interprofessional team?

A nurse is collecting data from a client who is 12 hr postoperative following intestinal surgery. Which of the following findings should the nurse report to the charge nurse prior to client ambulation?

A nurse in an adult day care facility is contributing to the plan of care for a client whose family reports recent confusion and memory loss. Which of the following strategies should the nurse include in the plan?