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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Clustering nursing care activities minimizes disruptions to the client, reduces fatigue, and allows for periods of rest in between interventions.
Choice B rationale:
Hyperoxygenating the client before suctioning helps maintain adequate oxygenation and prevents hypoxia during the suctioning procedure.
Choice C rationale:
Keeping the room well lit is not necessary for a client on mechanical ventilation and can actually disturb their rest.
Choice D rationale:
Maintaining a specific PaCO2 level might be important for some clients, but this is not a general action applicable to all mechanically ventilated clients.
Correct Answer is A
Explanation
Choice A rationale:
Elevating the head of the bed can help prevent intracranial pressure by promoting venous drainage from the head.
Choice B rationale:
Premature newborns need to rest and conserve energy, so excessive stimulation every 2 hours is not recommended.
Choice C rationale:
Placing the newborn in a radiant warmer helps maintain a stable body temperature, but it does not directly address intracranial pressure.
Choice D rationale:
Administering hypertonic solution is not a standard intervention for decreasing intracranial pressure in a premature newborn.
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