A nurse is performing an admission assessment for an older adult client. The nurse should identify that which of the following findings is a manifestation of possible elder maltreatment?

The client has decreased muscle mass.

The client's eyes have white circles surrounding the cornea.

The client's clothes have a urine odor.

The client has nodules on the metacarpal joints.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Decreased muscle mass can be a normal age-related change in older adults and is not necessarily indicative of elder maltreatment.

Choice B rationale:

White circles surrounding the cornea (arcus senilis) is a common age- related finding and is not necessarily indicative of elder maltreatment.

Choice C rationale:

The presence of urine odor on the client's clothes could indicate neglect or inadequate care and should be further investigated.

Choice D rationale:

Nodules on the metacarpal joints may be related to osteoarthritis, which is a common condition in older adults and may not necessarily indicate elder maltreatment.

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Correct Answer is C

Explanation

Choice A rationale:

Thawing frozen foods at room temperature can promote bacterial growth, increasing the risk of foodborne illness.

Choice B rationale:

There is no need for the client to reduce their intake of calcium-containing foods specifically to prevent foodborne illness. Calcium-containing foods are not associated with an increased risk of bacterial contamination.

Choice C rationale:

Cooking raw fish and steak to the well-done stage is recommended to kill harmful bacteria and reduce the risk of foodborne illness, which is particularly important for individuals with neutropenia who are more susceptible to infections.

Choice D rationale:

Cutting damaged areas from fruits and vegetables is a good practice to reduce the risk of contamination, but it does not address the risk of bacterial contamination from undercooked meat and fish.

A. Use a disposable adhesive probe when measuring the client's SaO2 B. Wrap a blood pressure cuff in a stockinette for use in the client's room. C. Document in the medical record that the client should not use silicone products. D. Clean vial stoppers for 15 seconds before using them to withdraw-medications for the client.

Correct Answer is B

Explanation

Choice A rationale:

Using a disposable adhesive probe when measuring the client's SaO2 is not an intervention that can reduce the exposure of the client to latex, because adhesive probes may contain latex and cause skin reactions. A better option would be to use a non-adhesive probe or a probe cover that is latex-free.

Choice B rationale:

Rationale: Latex sensitivity or allergy can lead to adverse reactions when exposed to latex- containing products, such as blood pressure cuffs. Wrapping the blood pressure cuff in a stockinette helps minimize direct contact between the cuff and the client's skin.

Choice C rationale:

Silicone products are usually considered safe for individuals with latex sensitivity because silicone is a different material. Silicone products are generally safe for clients who are sensitive to latex, unless they have a separate allergy to silicone.

Choice D rationale:

Cleaning vial stoppers for 15 seconds before using them to withdraw-medications for the client is not an intervention that can reduce the exposure of the client to latex, because vial stoppers may be made of latex or rubber and cleaning them does not remove the allergen. A better option would be to use vials that have latex-free stoppers or to avoid puncturing the stoppers with needles.

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A nurse is performing an admission assessment for an older adult client. The nurse should identify that which of the following findings is a manifestation of possible elder maltreatment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has neutropenia about preventing foodborne illness. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

A nurse is caring for a client who is suspected to have developed sensitivity to latex. Which of the following interventions should the nurse plan to implement?

Correct Answer is B

Explanation

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