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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 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."

"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

Answer and Explanation

The Correct Answer is ["B","C","D","G"]

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."

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

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Socialization can promote trust and reduce isolation, so limiting socialization is not beneficial.

B. Speaking in a neutral tone helps build trust and reduces perceived threats in clients with paranoid personality disorder, who may be suspicious of others' intentions.

C. Consistency in caregivers fosters trust, so rotating staff frequently may exacerbate the client's paranoia.

D. Mixing medication with food without the client's knowledge breaches trust and ethical guidelines.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}

Explanation

Transient tachypnea of the newborn: The newborn's elevated respiratory rate and mild grunting are indicative of transient tachypnea, a condition where the baby breathes too fast due to retained lung fluid.
Hypoglycemia: Newborns, especially those with higher birth weights, are at risk for hypoglycemia, which can be exacerbated by stress and increased energy expenditure due to rapid breathing.

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Body Systems	Findings
Respiratory	Respiratory rate 26/min
Cardiovascular	Heart rate 112/min Capillary refill 4 seconds
Gastrointestinal	Hyperactive bowel sounds
Integumentary	Diaper area reddened with erythema noted Extremities cool Reports no tears
Neurologic	Lethargic

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is creating a plan of care for a client who has paranoid personality disorder and refuses to take their medication. Which of the following interventions should the nurse include in the plan?

Correct Answer is B

Explanation

A nurse is caring for a newborn. Exhibits SELECT words from the choices below to fill in each blank in the following sentence. The client is at risk for developing ________ and ___________

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}

Explanation

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