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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.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Schedule the client for retesting in 1 week: Retesting is typically done after 3 months, not 1 week.

B. Administer ceftriaxone via intermittent IV bolus: Ceftriaxone is used for gonorrhea, not chlamydia.

C. Instruct the client to abstain from sexual intercourse for 1 month: Abstinence is recommended until treatment is completed and partners are treated, not necessarily for 1 month.

D. Report the infection to the state department of health: Reporting is required by law to help track and reduce the spread of STIs.

A. Ensure that the transfusion is completed within 6 hr. B. Obtain venous access using a 22-gauge needle. C. Store the unit of blood at room temperature for 1 hr prior to the infusion. D. Use a solution of 0.9% sodium chloride to flush the transfusion tubing.

Correct Answer is D

Explanation

A. Ensure that the transfusion is completed within 6 hr: Incorrect. Blood transfusions should be completed within 4 hours to reduce the risk of bacterial contamination.

B. Obtain venous access using a 22-gauge needle: Incorrect. A larger gauge (18-20) is preferred to prevent hemolysis and allow for faster administration.

C. Store the unit of blood at room temperature for 1 hr prior to the infusion: Incorrect. Blood should remain refrigerated until it is ready to be transfused, and it should be started within 30 minutes of removal from refrigeration.

D. Use a solution of 0.9% sodium chloride to flush the transfusion tubing: 0.9% sodium chloride is the only compatible solution with blood products to prevent hemolysis.

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