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."

A school nurse is performing scoliosis screenings. The nurse should recognize which of the following clinical manifestations as an indication of scoliosis?

A nurse is caring for a client whose child died from cancer. The client states, "It's hard to go on without him." Which of the following questions should the nurse ask the client first?

A nurse is caring for a client who is near the end of life and is on complete bed rest. The client states that he needs to have a bowel movement, and the nurse offers a bed pan. The client states, "I've always used the bathroom." Which of the following responses should the nurse make?

A nurse is caring for a client in the emergency department.

Select the 4 interventions nurse should take.

A nurse is planning teaching for a client who has a newly implanted implantable cardioverter/defibrillator. Which of the following information should the nurse include?

A nurse is assessing a client who received hydromorphone 4 mg IV 15 min ago. The client has a respiratory rate of 10/min. The nurse should prepare to administer which of the following medications?

A nurse is obtaining the temperature of a newborn. Which of the following sites should the nurse use?

A nurse is caring for a client who experienced a traumatic brain injury 72 hr ago. Which in the client's findings are potential indication of increased intracranial pressure?

A nurse is speaking with the caregiver of a client who has Alzheimer's disease. The caregiver states, "Providing constant care is very stressful and is affecting all areas of my life." Which of the following actions should the nurse take?

A nurse working in the emergency department (ED) is admitting a client.

The nurse is reviewing the client's medical record. Which of the following conditions should the nurse identify as a risk factor for pneumonia? Select all that apply.