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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Effleurage is a massage technique commonly used during labor to provide comfort and relaxation. It involves using gentle, rhythmic stroking movements on the abdomen during contractions. This technique can help relieve tension, promote relaxation, and provide distraction from the intensity of the contractions.
Deep breathing techniques are often used during labor to promote relaxation and manage pain. However, this instruction does not specifically relate to effleurage.
Focusing on an object in the room, such as a focal point, can be a helpful technique during labor to redirect attention and manage pain. However, this instruction does not specifically relate to effleurage.
Applying pressure to the sacral area can help alleviate back pain during labor. However, this instruction describes the use of a tennis ball and is not specifically related to effleurage.
Correct Answer is B
Explanation
Tranylcypromine is a monoamine oxidase inhibitor (MAOI) medication used to treat depression. MAOIs inhibit the activity of the enzyme monoamine oxidase, which helps regulate the breakdown of certain neurotransmitters, including tyramine. Tyramine is typically broken down by monoamine oxidase, but when taking an MAOI, the enzyme's inhibition can lead to an excessive accumulation of tyramine in the body.
Tyramine-rich foods, such as aged cheeses, cured meats, and certain fermented or pickled foods, contain high levels of tyramine. Ingesting these foods while taking an MAOI can lead to a sudden release of stored norepinephrine, causing a hypertensive crisis.
Hypertension is a potentially serious adverse effect of MAOI therapy combined with tyramine-rich food ingestion. Symptoms of a hypertensive crisis can include severe headache, palpitations, chest pain, sweating, blurred vision, and in severe cases, it can lead to stroke or other cardiovascular complications.
Hematuria refers to the presence of blood in the urine and is not a known adverse effect of tranylcypromine or related to tyramine-rich food ingestion.
Tinnitus refers to the perception of ringing or noise in the ears and is not a known adverse effect of tranylcypromine or related to tyramine-rich food ingestion.
Hyperglycemia, or high blood sugar levels, is not a known adverse effect of tranylcypromine or related to tyramine-rich food ingestion. However, it's important to note that tranylcypromine may interact with certain diabetes medications, so it's essential to consider the client's overall medical history and potential drug interactions.
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