A nurse is caring for an older adult client.
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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 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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
Nurses' Notes
0900:
Client who is at 38 weeks of gestation presents to the antepartum unit with uterine contractions, dark red vaginal bleeding, and abdominal pain that started approximately 45 min prior to arrival. Rates abdominal pain a 7 on a scale of 0 to 10. Client reports, "My blood pressure has been high during the pregnancy."
Home Medications: prenatal multivitamin, methyldopa 250 mg PO twice daily Physical Exam:
General: tearful, anxious
Cardiovascular: S1, S2, no murmur
Respiratory: bilateral breath sounds clear
Abdomen: Uterine hypertonicity with a board-like abdomen, tenderness noted upon palpation of left upper quadrant
FHR: 116/min, minimal variability noted
Rationale:
Dark red vaginal bleeding: This could indicate a serious complication such as placental abruption, which can lead to fetal and maternal distress. Dark red bleeding is often associated with this condition and requires immediate follow-up to determine the source and to prevent further complications.
Uterine hypertonicity with a board-like abdomen: Uterine hypertonicity and a "board-like" abdomen may suggest uterine contractions that are intense or sustained, which could be associated with placental abruption or other serious obstetric complications. This finding needs follow-up to assess for uterine rupture, abruption, or other causes of uterine distress.
Pain score of 7/10: The client's moderate-to-severe pain (rated 7/10) requires follow-up to manage pain and evaluate for its cause. Pain related to placental abruption or other complications may be severe and should be managed appropriately.
FHR of 116/min with minimal variability: A fetal heart rate (FHR) of 116/min is within the normal range, but minimal variability could suggest fetal distress or compromise. Follow-up is needed to continuously monitor fetal well-being and assess for any changes in FHR patterns.
Correct Answer is C
Explanation
A. Assessing IV patency is important but comes after confirming the client is not allergic.
B. Checking compatibility ensures safe administration but is not the first priority.
C. Reviewing the client's allergy history is the priority to prevent a potentially life-threatening allergic reaction.
D. Obtaining the medication is necessary but only after confirming it is safe for the client.
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