A nurse is caring for an older adult client.
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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." |
expressing concern over memory and thought process, appetite, and self-care
lost about 8 lb in the past month
"Why don't you just leave me? I am of no use."
speaks in a monotone voice
The Correct Answer is ["A","B","C"]
- This is a concerning finding because the adult child reports cognitive and physical decline in the client, which could indicate severe memory loss, cognitive impairment, or potentially dementia or other mental health conditions such as depression or suicidal ideation.
- Significant weight loss and decreased appetite in an older adult can indicate serious conditions, including malnutrition, depression, or potentially serious medical conditions such as cancer or other chronic diseases. Immediate follow-up is needed to assess the cause of the weight loss, evaluate the client’s nutritional status, and address any underlying health concerns.
- This statement is concerning because it suggests the client may be experiencing depression or suicidal ideation. Older adults are particularly vulnerable to depression, and this expression of worthlessness is a red flag that the client could be at risk for suicide. The nurse shouldimmediately assess the client’s mental health status, ask about thoughts of self-harm, and potentially initiate a psychiatric evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Elevated fasting blood glucose is a concern but does not immediately contraindicate clozapine administration. It can be monitored and managed.
B. Clozapine can cause agranulocytosis, and a low absolute neutrophil count (ANC) is a contraindication for the medication. The threshold for stopping clozapine is typically an ANC of less than 1,500/mm3.
C. A heart rate of 58/min is not a contraindication for clozapine. It may require monitoring but is not necessarily concerning.
D. An Hgb level of 12.5 g/dL is within the normal range and does not contraindicate the use of clozapine.
Correct Answer is B
Explanation
A. Advancing the catheter before releasing the tourniquet can increase the risk of trauma and difficulty in catheter placement.
B. Releasing the tourniquet is the correct step after confirming blood return to reduce venous congestion and ease the advancement of the catheter.
C. The stylet should not be retracted until the catheter is properly placed in the vein.
D. Flushing the catheter with saline should only be done once the catheter is properly secured in the vein.
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