A public health nurse is assessing an older adult client who lives with a family member.

The nurse identifies several bruises in various stages of healing. The client and family members explain that the bruises are a result of clumsiness. However, based on the distribution of the bruises, the nurse suspects abuse.

Which of the following actions should the nurse take first?

Investigate further to confirm the suspicion.

Report the findings.

Provide the client with a crisis hotline number.

Discuss respite care with the client’s family.

Answer and Explanation

The Correct Answer is B

The nurse has a legal and ethical obligation to report any suspected abuse of a vulnerable client, such as an older adult. Reporting the findings is the first action the nurse should take to protect the client and initiate an investigation by the appropriate authorities.

Choice A is wrong because investigating further to confirm the suspicion is not within the nurse’s scope of practice and could delay the reporting process.

Choice C is wrong because providing the client with a crisis hotline number is not enough to ensure the client’s safety and well-being.

The client might not be able to access the hotline or might be afraid to use it.

Choice D is wrong because discussing respite care with the client’s family is not appropriate at this stage.

The nurse should not assume that the family member is willing or able to provide adequate care for the client.

Respite care might be an option after the abuse is reported and investigated.

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Correct Answer is C

Explanation

Giving a report to a provider in SBAR format is not related to one of the National Patient Safety Goals (NPSGs). The NPSGs are a set of standards developed by The Joint Commission to improve patient safety andquality of care. They address specific areas of concern such as infection prevention, medication safety, patient identification, communication, and alarm management.

Choice A is wrong because refraining from changing alarm settings is related to NPSG 06.01.01, which aims to improve the safety of clinical alarm systems. Choice B is wrong because using 2 patient identifiers for medication administration is related to NPSG 01.01.01, which aims to improve the accuracy of patient identification.

Choice D is wrong because arriving 15 minutes prior to the start of the shift is related to NPSG 02.03.01, which aims to improve the effectiveness of communication among caregivers.

A. Patient will check his blood sugar every day until his follow-up appointment. B. Patient will discuss their feelings about required dietary changes (anti inflammatory diet) by discharge. C. Patient will state 3 ways to avoid his known triggers (cat dander and pollen) by the end of the shift. D. Patient will demonstrate proper use of inhaler by end of the shift.

Correct Answer is C

Explanation

This is because the cognitive domain of learning involves knowledge and understanding of information. By stating 3 ways to avoid his triggers, the patient demonstrates that he has learned and comprehended the information about prevention of inflammation.

Choice A is wrong because it belongs to the psychomotor domain of learning, which reflects learning behavior achieved through neuromuscular motor activities. Checking blood sugar is a physical skill, not a cognitive one.

Choice B is wrong because it belongs to the affective domain of learning, which characterizes the emotional arena reflected by learners’ beliefs, values and interests.

Discussing feelings about dietary changes is an affective outcome, not a cognitive one.

Choice D is wrong because it also belongs to the psychomotor domain of learning, as it involves demonstrating proper use of inhaler, which is another physical skill.

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Naxlex Comprehensive Predictor Exams

A new nurse is working in a hospital. Which of the following actions by the nurse is NOT related to one of the National Patient Safety Goals?

Correct Answer is C

Explanation

A nurse is utilizing the cognitive domain of learning to teach a patient about the prevention of inflammation. Which of the following is an appropriate goal for this patient?

Correct Answer is C

Explanation

A client who is at risk for developing osteoporosis asks what can be done to decrease the risk of actually developing the disorder. Which intervention would be the most beneficial for this client?

A nurse is teaching about values to a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding?

The RN identifies that a client is at risk for impaired skin integrity. Which interventions should the nurse add to this client’s plan of care?

The nurse includes which of the following as an appropriately constructed goal statement for the client with COPD?

While preparing a client for surgery, the nurse marks the arm that is to be amputated and participates in a “time-out” procedure before the surgery begins. Which sentinel event is this action intended to prevent?

A nurse is assessing a client who was brought to the emergency department with an ankle injury. Which of the following manifestations should the nurse identify as localized inflammation of the tissues?

A nurse is assisting with teaching a class about physical manifestations associated with the fight-or-flight response to stress. Which of the following manifestations should the nurse include?