A nurse is caring for an older adult client.
Adult child accompanying parent reports cognitive and physical decline in the client, expressing concern over memory loss, thought processes, appetite, and self-care. Adult child states, "My sibling and I hired help at home for my parent. We thought that might help, but it has not. I found the title to the car today, signed over to me.".
Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression.
Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom." Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month.
1030:.
Client found sitting in waiting room, head in hands. Client says, "Why don't you just leave me? I am of no use.”.
Vital Signs. 0945:.
Temperature 37.7° C (99.9° F). Heart rate 68/min.
Respiratory rate 16/min. BP 136/80 mm Hg.
Oxygen saturation 100% on room air.
Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.
System |
Findings |
General |
Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states. "My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me." |
Physical |
Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom." Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min |
Affect |
Client says. "Why don't you just leave me? I am of no use.” |
The Correct Answer is ["The findings that require immediate follow-up are:.\r\n\u2022\tAdult child accompanying parent reports decline in client"," expressing concern over memory and thought process"," appetite"," and self-care. Adult child states. \u201cMy sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today"," signed over to me.\u201d.\r\n\u2022\tClient makes poor eye contact"," speaks in a monotone voice"," and has a lack of facial expression. Client reports not wanting to eat anymore. Client\u2019s child reports their parent has lost about 8 lb in the past month.\r\n\u2022\tClient says. \"Why don\u2019t you just leave me? I am of no use.\u201d.\r\nThese findings suggest that the client may have cognitive impairment"," depression"," and\/or malnutrition"," which can affect their health and quality of life. The nurse should perform a comprehensive assessment of the client\u2019s cognitive"," behavioral"," and functional status"," review their medications and possible side effects"," provide education and support for healthy aging"," and collaborate with interdisciplinary teams and community resources. The nurse should also evaluate the client\u2019s home environment and lifestyle"," and consider nonpharmacological approaches to manage behavioral problems. The nurse should also monitor the client\u2019s vital signs and weight regularly."]
The findings that require immediate follow-up are:.
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- Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states. “My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me.”.
- Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports not wanting to eat anymore. Client’s child reports their parent has lost about 8 lb in the past month.
- Client says. "Why don’t you just leave me? I am of no use.”.
These findings suggest that the client may have cognitive impairment, depression, and/or malnutrition, which can affect their health and quality of life. The nurse should perform a comprehensive assessment of the client’s cognitive, behavioral, and functional status, review their medications and possible side effects, provide education and support for healthy aging, and collaborate with interdisciplinary teams and community resources. The nurse should also evaluate the client’s home environment and lifestyle, and consider nonpharmacological approaches to manage behavioral problems. The nurse should also monitor the client’s vital signs and weight regularly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Perform a sterile dressing change for a client who has an abdominal wound. This is because a licensed practical nurse (LPN) can perform tasks that require technical skills and have predictable outcomes, such as dressing changes. A sterile dressing change is also within the scope of practice of an LPN.
Choice A is wrong because complete discharge teaching for a client who has a new diagnosis of diabetes mellitus requires assessment, evaluation and critical thinking, which are beyond the scope of practice of an LPN. Discharge teaching is the responsibility of a registered nurse (RN) who can provide education and counseling to clients and families.
Choice B is wrong because completing the Glasgow Coma Scale for a client who has an evolving stroke requires assessment and interpretation of neurological status, which are complex and unpredictable tasks that only an RN can perform. The Glasgow Coma Scale is a tool that measures the level of consciousness of a client based on eye opening, verbal response and motor response. A client who has an evolving stroke may have changes in their neurological status that require frequent monitoring and intervention by an RN.
Choice D is wrong because performing an admission assessment for a client who is scheduled for surgery requires comprehensive data collection, analysis and synthesis, which are advanced skills that only an RN can perform. An admission assessment involves obtaining a complete health history, performing a physical examination, identifying client needs and problems, and developing a plan of care.
A client who is scheduled for surgery may have complex and unpredictable needs that require specialized knowledge and judgment by an RN.
Correct Answer is C
Explanation
This is because varicella, or chickenpox, is a highly contagious disease caused by the varicellazoster virus (VZV), which can spread through the air or by direct contact with the fluid from the blisters. A negative air pressure room prevents the air from the room from circulating to other areas of the hospital, reducing the risk of transmission to other patients and staff.
Choice A is wrong because aspirin should not be given to children with chickenpox, as it can cause a serious condition called Reye’s syndrome, which affects the brain and liver. Instead, acetaminophen can be used to reduce fever.
Choice B is wrong because droplet precautions are not enough to prevent the spread of chickenpox. Droplet precautions involve wearing a mask and gloves when in close contact with the patient, but they do not prevent the virus from traveling through the air. Airborne precautions, which include a negative air pressure room and wearing a respirator, are needed for chickenpox.
Choice D is wrong because Koplik spots are not a sign of chickenpox, but of measles, another viral infection that causes a rash. Chickenpox causes an itchy rash with small, fluid-filled blisters that crust over.
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