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 A

Explanation

This helps increase the oxygen-carrying capacity of the blood and corrects anemia.

Choice B is wrong because erythropoietin is not given to all people with anemia. It is only used for certain types of anemia, such as those caused by chronic kidney disease or chemotherapy.

Choice C is wrong because erythropoietin is not given for iron deficiency anemia. Iron deficiency anemia is treated with iron supplements and dietary changes.

Choice D is wrong because erythropoietin does not stimulate bone marrow production of white blood cells. White blood cells are involved in immune responses and are produced by different growth factors.

Question 22.

A. Keep call bell within the client’s reach. B. Keep a dim light on at night. C. Keep unnecessary furniture out of the way. D. Keep all side rails up at all times. E. Keep all lights off at night.

Correct Answer is ["A","B","C"]

Explanation

These actions ensure the safety of the client by reducing the risk of falls, confusion and injury.

Keeping a call bell within the client’s reach allows them to ask for help when needed.

Keeping a dim light on at night helps them orient themselves and see their surroundings.

Keeping unnecessary furniture out of the way prevents tripping and cluttering. Choice D is wrong because keeping all side rails up at all times can be considered a form of physical restraint, which is associated with many professional, legal and ethical challenges. Physical restraint should only be used as a last resort when other alternatives have failed or are not feasible. Keeping all side rails up can also increase the risk of injury if the client tries to climb over them.

Choice E is wrong because keeping all lights off at night can increase the risk of falls and confusion for the client.

Older adults may have impaired vision and cognition, and they may need to use the bathroom frequently at night. Keeping all lights off can make it difficult for them to find their way and increase their anxiety.

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Naxlex Comprehensive Predictor Exams

A person with anemia is prescribed erythropoietin subcutaneously. The nurse knows that erythropoietin:

Correct Answer is A

Explanation

An elderly client is hospitalized for the first time. Which of the following actions ensures the safety of the client? (Select all that apply).

Correct Answer is ["A","B","C"]

Explanation

The nurse is assigned to care for a client admitted to the hospital with chronic obstructive pulmonary disease (COPD). Which medication does the nurse anticipate to decrease this client’s risk for developing a respiratory infection?

A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse’s priority?

The RN performs an admission assessment and determines the client is a fall risk. What is a priority nursing intervention for this client?

A nurse is contributing to the plan of care for a client who has COPD. Which of the following interventions should the nurse include in the plan of care?

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?

An elderly client is admitted to the hospital looking unkempt, with dirty clothing, and she smells of urine. The nurse is aware this may be:

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?

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