An older adult client is admitted to a long term care facility. Upon admission, the client is oriented but fatigued, is incontinent of urine, and has a stage II pressure ulcer on the left heel. Which additional finding requires further assessment?

Absorbent undergarments dry for 6 hours.

Heel dressing saturated with serous drainage.

Frequent request for medication to sleep.

Confusion to time, place, and environment.

Answer and Explanation

The Correct Answer is D

A.   While the use of absorbent undergarments is relevant to managing urinary incontinence, having them dry for 6 hours indicates that they are performing their function well in terms of absorbing urine. This finding does not immediately suggest a new issue that needs urgent further assessment.
B.   A heel dressing saturated with serous drainage suggests that the stage II pressure ulcer on the left heel is producing a significant amount of fluid. Serous drainage is typically clear or light yellow and can indicate a wound that is still in the inflammatory phase of healing
C.   Frequent requests for sleep medication can indicate issues with sleep patterns or underlying psychological stress. While it’s important to address sleep difficulties, this finding might not be as immediately critical as other concerns but warrants further assessment to address possible underlying causes and manage sleep issues appropriately.
D.   Confusion about time, place, and environment in a newly admitted client is a significant finding and requires urgent further assessment. This level of confusion could be indicative of a serious issue such as delirium, which can be caused by various factors including infection, dehydration, metabolic imbalances, or a sudden change in environment.

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Correct Answer is A

Explanation

A. This action is essential for effectively representing the client. Developing self-awareness of personal values ensures that the nurse does not impose their own beliefs on the client’s decisions. Instead, the nurse can advocate for the client's wishes based on the client's values and preferences, not their own.
B. While listening to the ethics committee is important, the nurse’s role as an advocate is to represent the client’s wishes and interests, not to dictate actions based on committee discussions. Informing the
client what actions should be taken may not be appropriate if it does not align with the client’s values or
preferences.
C. While it is important to advocate for the client's wishes, challenging team members should be done respectfully and constructively. The goal is not to create conflict but to ensure that the client’s preferences are considered.
D. Educating the client about nursing literature may be helpful, but it is not the primary responsibility of the nurse when serving as an advocate in an ethics committee meeting. The focus should be on
understanding and representing the client’s values and wishes rather than providing educational
information, unless it directly influences the client’s decision-making process.

A. Ask the client how often episodes of sun downing are experienced. B. Assist the client with values clarification about end-of-life care options. C. Question the client about the frequency of falls in recent months. D. Request to have the client lie as still as possible for the assessment.

Correct Answer is C

Explanation

A. Sundowning refers to confusion and agitation that typically occurs in the late afternoon or evening in some individuals with dementia or other cognitive impairments. While important for understanding the client’s cognitive and behavioral patterns, this question is more specific to cognitive or behavioral issues rather than directly assessing functional abilities.
B. Values clarification regarding end-of-life care is crucial, especially for advanced planning and ensuring that care aligns with the client’s preferences. However, this is typically part of a different type of discussion and planning, rather than a general functional assessment.
C. Inquiring about recent falls is a relevant component of a functional assessment. Falls can indicate issues with mobility, balance, strength, or cognitive function, all of which are critical for assessing a client's need for nursing home care. Understanding the frequency and circumstances of falls helps in evaluating the client's overall safety and functional status, which is essential for planning appropriate care.
D. Asking the client to lie still is not typically relevant or necessary for a functional assessment, which
generally involves evaluating the client’s ability to perform activities of daily living (ADLs), mobility, and overall function. A functional assessment often involves observing the client’s movement, activities, and responses, which requires them to be active and engaged rather than lying still.

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An older adult client is admitted to a long term care facility. Upon admission, the client is oriented but fatigued, is incontinent of urine, and has a stage II pressure ulcer on the left heel. Which additional finding requires further assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse has agreed to serve as a client's advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, what action is essential for the nurse to take?

Correct Answer is A

Explanation

The nurse is performing a functional assessment for a client requiring nursing home care. During the client interview, which action should the nurse implement?

Correct Answer is C

Explanation

Prior to receiving a 120 mL hypertonic enema, an ambulatory female client tells the nurse that she does not believe that she can walk all the way to the bathroom without expelling the enema. Which intervention is best for the nurse to implement?

While changing the dressing of a client who is immobile, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

When preparing to change a client's sterile dressing, the nurse pours sterile solution over a package of gauze pads as seen in the picture. Which should the nurse do next?

The nurse attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

A client who has a continuous tube feeding develops a fever and reports experiencing dyspnea. Which action should the nurse implement?

A client started a 24-hour urine collection several hours ago. The client tells the nurse that the last voiding was accidentally flushed instead of saved in the container. Which intervention should the nurse initiate?

The nurse observes that a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?