A nurse is caring for an older adult client being admitted into a long-term care facility.
Complete the following sentence by using the list of options.
The nurse should address the client's
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Rationale for correct choices:
- Safety: The client has an unsteady gait, dizziness on standing, ecchymosis in multiple healing stages, and abrasions, all of which raise concerns for recurrent falls or possible neglect. Ensuring the client’s immediate safety is the top priority before addressing other needs.
- Notify Adult Protective Services: Scattered ecchymoses in different healing stages, poor hygiene, and possible neglect warrant a report to APS for further investigation to ensure the client’s protection.
Rationale for incorrect choices:
- Hygiene: While poor hygiene, lice infestation, and odor are evident, these concerns are not immediately life-threatening compared to the safety risks of falls and potential abuse or neglect. They can be addressed after the client is safe and protected.
- Nutrition: No clear evidence of malnutrition is provided, though decreased skin turgor suggests possible dehydration. However, nutrition needs are a lower priority than immediate safety concerns related to falls and potential abuse.
- Arrange for dietary consult: This intervention would be appropriate later for long-term care planning, but it does not address the client’s most urgent risk factors.
- Consult with social services for support: Social services may help coordinate resources, but urgent reporting to APS is needed first because of suspected neglect and abuse indicators.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. 15°: This angle is used for intradermal injections, such as a tuberculin skin test, where the medication is deposited just under the epidermis. It would not allow the needle to reach the muscle layer, making it inappropriate for intramuscular administration.
B. 60°: An angle of 60° is not a standard technique for any specific injection type. At this angle, the medication would likely end up in the subcutaneous tissue instead of the muscle, leading to improper absorption and reduced effectiveness.
C. 45°: This angle is appropriate for subcutaneous injections, such as insulin, when a shorter needle is used or in thin clients. It does not penetrate deeply enough to reach the muscle tissue for intramuscular medication administration.
D. 90°: A 90° angle ensures the needle penetrates through the subcutaneous tissue and into the muscle, which is necessary for intramuscular injections. This angle allows the medication to be deposited directly into the muscle for proper absorption and therapeutic effect.
Correct Answer is "{\"xRanges\":[33.882846916299556,42.693419603524234],\"yRanges\":[29.535864978902953,37.9746835443038]}"
Explanation
A. Throat/Pharynx area: The gag reflex must be checked before giving fluids. Anesthetics used during bronchoscopy suppress the gag and cough reflex, which places the client at high risk of aspiration. Assessing the throat for return of reflexes ensures safe swallowing.
B. Head/Brain area: Assessing the brain is not necessary prior to resuming oral intake after bronchoscopy. Neurological function is important overall, but it does not determine whether the swallowing reflex has returned and if the client can safely manage oral fluids.
C. Mouth/Lips: Examining the lips or oral cavity may reveal dryness, bleeding, or trauma, but it does not determine readiness for fluids. The risk of aspiration persists unless gag reflex recovery is confirmed.
D. Chest/Lungs area: Assessing lung sounds is important for evaluating complications such as bronchospasm or pneumothorax, but this does not confirm readiness for oral intake. Aspiration risk remains the main concern until gag reflex recovery is established.
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