A nurse is caring for an older adult client.

Exhibits

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."

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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. A recent hip arthroplasty puts the client at risk for bleeding if alteplase is administered, as there is a potential for hemorrhage at the surgical site.
B. Acute renal failure may affect medication clearance but is not a contraindication for alteplase.
C. Chronic obstructive pulmonary disease (COPD) does not place the client at risk for alteplase therapy.
D. A family history of malignant hypertension does not directly affect the safety of alteplase therapy.

A. "I can infuse the medication at a faster rate." B. "I can start the medication 30 minutes earlier." C. "I have up to 2 hours after the usual schedule time to give you this medication." D. "I can adjust the time and schedule for when it's convenient for you."

Correct Answer is C

Explanation

A. Infusing vancomycin at a faster rate could increase the risk of infusion-related reactions such as "red man syndrome" and is not recommended.
B. While a slight adjustment may be possible, 30 minutes is a short timeframe, and altering the time significantly could affect the therapeutic efficacy or safety of the drug.
C. The nurse typically has a 2-hour window to administer medications like vancomycin, but this should be done according to facility policy and the specific medication schedule.
D. Adjusting the time and schedule to the client's convenience may not ensure that the medication is administered effectively and within the proper timeframe.

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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."

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is reviewing the medical record of a client who is having an acute myocardial infarction. Which of the following findings places the client at risk if he receives alteplase?

Correct Answer is A

Explanation

A nurse is preparing to administer vancomycin IV to an adult client. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse make?

Correct Answer is C

Explanation

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