A nurse is caring for an older adult client.
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System |
Findings |
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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. |
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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 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 |
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Affect |
Client says, "Why don't you just leave me? I am of no use." |
"My sibling and I hired help at home for my parent.
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 says, "Why don't you just leave me? I am of no use."
Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom."
Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 Ib in the past month.
Heart rate 68/min
The Correct Answer is ["B","C","D","G"]
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System |
Findings |
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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." |
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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 |
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Affect |
Client says, "Why don't you just leave me? I am of no use." |
Rationale
These findings suggest significant cognitive and physical decline, potential depression, and possible suicidal ideation, all of which require immediate attention and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
Sepsis: Preterm neonates are at increased risk for infections, including sepsis. Discontinuation of feedings, along with the other signs observed (such as abdominal distention, blood in stool, lethargy, and hypotonia), may suggest the onset of infection, which requires close monitoring.
Hypotension: Preterm neonates are also at risk for hypotension due to immature circulatory systems. The stress of gastrointestinal disturbances, such as abdominal distention and the potential for necrotizing enterocolitis (NEC), can result in decreased perfusion, contributing to hypotension.
Correct Answer is C
Explanation
A. While medication may be helpful for sleep disturbances, offering sleep aids should not be the first response. Respite care is a more appropriate solution.
B. Although caring for someone who is terminally ill can be challenging, this response lacks empathy and does not offer practical support.
C. Respite care provides relief for caregivers by allowing them to take time off, which is appropriate for this situation.
D. While encouraging the son’s efforts is important, this response doesn't address the son's need for support or practical help with his own well-being.
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