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 A
Explanation
A. Use a reflex hammer: Clonus is assessed by using a reflex hammer to test deep tendon reflexes, typically at the ankle joint. Sustained rhythmic contractions following dorsiflexion of the foot confirm the presence of clonus, which often indicates upper motor neuron dysfunction.
B. Administer magnesium sulfate: Magnesium sulfate is a treatment used in conditions such as preeclampsia with severe features but is not a method of assessment. Medication administration would come after clonus has been identified, not during the diagnostic step.
C. Perform a Romberg test: The Romberg test assesses balance and proprioception, often used in neurological exams for cerebellar or sensory dysfunction. It does not evaluate for clonus, which specifically relates to abnormal reflex activity.
D. Test the gait for symmetry: Gait assessment provides information about coordination, strength, and balance. While it may reveal neurologic impairment, it does not directly test for clonus or identify the rhythmic contractions associated with it.
Correct Answer is ["B","C","E"]
Explanation
A. Schedule the client as the last surgery of the day: Clients with latex allergy should ideally be scheduled as the first surgery of the day to minimize exposure to latex particles that may accumulate in the air and environment. Scheduling last increases exposure risk.
B. Notify ancillary departments of the client's allergy: Informing all relevant departments, such as pharmacy, radiology, and laboratory services, ensures that latex-free supplies are used consistently throughout the client’s care. This prevents accidental exposure to latex-containing products.
C. Label the surgical suite as latex-free: Clearly labeling the operating room reduces the risk of staff inadvertently bringing in latex products. It promotes team-wide awareness and helps maintain a safe surgical environment for the client.
D. Provide powdered gloves for the staff's use: Powdered latex gloves are contraindicated because they release latex proteins into the air, which increases the risk of allergic reactions. Only non-latex, powder-free gloves should be provided.
E. Ensure a latex allergy cart is available: Having a latex allergy cart stocked with latex-free supplies ensures that all necessary items are available during the procedure. This reduces delays and eliminates the need to search for suitable equipment during surgery.
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