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

Nurses' Notes

Day 1, 12:00:

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

The client is soft-spoken, speaks almost in a whisper, and does not make eye contact with the nurse.

The 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." The 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 the power of attorney.

Answer and Explanation

Correct Answer : B,C,D

It is not appropriate for the nurse to threaten the client's child with reporting for maltreatment without further assessment and evidence.

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.

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.

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.

Providing legal advice regarding power of attorney 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 attorney should be assessed before providing such advice.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Whenever a medication error occurs, it should be documented in an incident report. The purpose of the incident report is to document the details of the event, including what happened, why it happened, and what was done to prevent it from happening again. Incident reports are not part of the client's medical record and are not used for disciplinary action. They are used for quality improvement and risk management purposes.

The nursing care plan is a document that outlines the client's nursing care needs and interventions. It is not the appropriate place to document a medication error.

The controlled substance inventory record is used to document the administration and dispensing of controlled substances. It is not the appropriate place to document a medication error.

The provider's progress notes document the provider's assessment, diagnosis, and treatment plan for the client. They are not the appropriate place to document a medication error.

A. Polyuria B. Pruritus C. Nervousness D. Cough

Correct Answer is C

Explanation

Thyrotoxicosis refers to a state of excess thyroid hormone in the body, which can occur as a result of excessive levothyroxine dosage or other causes. Nervousness is a common symptom of thyrotoxicosis, characterized by an excessive or uncontrollable feeling of anxiety or restlessness. It is important for the client to report this symptom to the healthcare provider because it may indicate an imbalance in thyroid hormone levels and may require adjustment of the medication dosage.

Polyuria, which refers to increased urination, is not a specific symptom of thyrotoxicosis. It can occur due to various factors unrelated to thyroid function.

Pruritus, or itching, is not a common symptom of thyrotoxicosis. It may be associated with other conditions or causes.

Cough is not typically associated with thyrotoxicosis. It is more commonly related to respiratory or pulmonary conditions rather than thyroid dysfunction.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hours PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this alert care incident?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who has hypothyroidism and a new prescription for levothyroxine. The nurse should instruct the client to notify the provider of which of the following manifestations of thyrotoxicosis?

Correct Answer is C

Explanation

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?

A nurse is collecting data from a client who is taking tranylcypromine and reports ingestion of tyramine-rich foods. The nurse should monitor the client for which of the following findings as an adverse effect of this medication?

A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hr PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this client care incident?

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse plan to take?

A nurse is assisting with the care of a client. Laboratory Results Abdominal ultrasound: mass present in small intestine proximal to the ileocecal valve. The size of mass is 6 cm x 7 cm (2.4 in x 2.8 in). Select the 4 responsibilities the nurse has in relation to the client's advance directives.

A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hours PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this alert care incident?

A nurse is reinforcing discharge teaching with a client who has a prescription for home oxygen therapy. Which of the following statements by the client indicates an understanding of the teaching?

A nurse working in a clinic is reinforcing teaching with a client who has hepatitis A. Which of the following client statements indicates an understanding of the teaching?