An older adult client is admitted to the hospital from a skilled care facility with dehydration and malnourishment. The client is oriented times four, but is despondent and withdrawn. The practical nurse (PN) observes that the client has multiple bruises on both arms and has poor hygiene. Which action should the PN implement first?

Document suspected abuse using the physical findings as supporting evidence.

Establish trust with the client to ensure basic needs and open communications are met.

Medicate the client as prescribed to ensure adequate rest and interventional therapies.

Contact social services to investigate the personnel at the skilled care facility.

Answer and Explanation

The Correct Answer is B

A. While documentation is essential, establishing a trusting relationship with the client is a more immediate priority to address their basic needs and gather information.
B. Establishing trust with the client is crucial to ensure their basic needs are met and to create an environment where the client feels safe to communicate openly. This foundational step is necessary before other interventions can be effectively implemented.
C. Medicating the client as prescribed is important for their overall care but does not address the immediate need to build trust and assess their situation comprehensively.
D. Contacting social services is a necessary step if abuse is suspected, but it should follow the initial assessment and establishment of trust with the client to gather accurate information.

Nursing Test Bank

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Correct Answer is ["C","D","E"]

Explanation

A. Limiting fresh fruits and vegetables is not necessary for clients with ascites due to cirrhosis unless they are causing specific issues like bloating or discomfort. Fresh fruits and vegetables are generally healthy and can be part of a balanced diet unless restricted for other reasons.
B. Consuming concentrated sweets to boost energy is not a recommended dietary strategy for managing ascites or cirrhosis. This approach may lead to excessive calorie intake without addressing the nutritional needs for a balanced diet.
C. Eating six small meals daily can help manage low appetite and energy levels by providing consistent nutrition throughout the day. Small, frequent meals are easier to consume and can help maintain adequate caloric intake for individuals with low appetite.
D. Choosing small helpings from lean protein sources is a good suggestion for managing ascites and cirrhosis. Lean proteins are important for maintaining muscle mass and supporting overall health without exacerbating liver disease.
E. Avoiding adding salt to foods helps manage fluid retention associated with ascites. Reducing sodium intake is crucial for managing ascites and preventing further fluid accumulation.

A. A team ring-toss competition. B. An open-air concert. C. A picnic in the park. D. A tea party in the courtyard.

Correct Answer is A

Explanation

A. This activity addresses both physical and social needs. It provides a gentle physical activity that can be enjoyed by people with limited mobility. It also encourages social interaction and teamwork, promoting a sense of belonging and camaraderie.
B. An open-air concert is enjoyable but may not fully engage residents in both physical and social aspects. While it offers entertainment, it lacks interactive elements that foster social engagement and physical involvement.
C. This activity requires more mobility than wheelchair-bound residents may have, especially if it involves walking on uneven terrain or sitting on the ground.
D. A tea party in the courtyard is a social activity but does not offer as much physical engagement or variety as a picnic in the park. While it is a pleasant option, it may not provide the same level of physical stimulation and change of scenery.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with recurrent ascites from cirrhosis describes having no appetite or energy to the home health practical nurse (PN). What diet suggestions should the PN provide for the client? Select all that apply.

Correct Answer is ["C","D","E"]

Explanation

The practical nurse (PN) is assisting the recreational director of a long-term care facility plan outdoor activities for the wheelchair-bound older residents who are mentally alert. Which activity meets the physical and social needs of these residents?

Correct Answer is A

Explanation

Exhibits The practical nurse (PN) re-educates the client on methicillin-resistant Staphylococcus aureus (MRSA). Click to indicate whether the client's statement(s) indicate understanding or no understanding. Each row must have one option selected.

The practical nurse (PN) is caring for a hospice client who requests a priest for the "Last Rites." Which should be the next response by the PN?

An unlicensed assistive personnel (UAP) is assisting with the care of a client with a peripherally inserted central venous catheter (PICC). Which guidance should the practical nurse (PN) provide to the UAP?

A client is using an incentive spirometer on the first postoperative day after an inguinal herniorrhaphy. The practical nurse (PN) should reteach the proper use of the spirometer when the client demonstrates which action?

The practical nurse (PN) and unlicensed assistive personnel (UAP) are providing care for a client who exhibits signs of neglect syndrome following a stroke affecting the right hemisphere. Which action should the PN implement?

In providing care for a client with a nasogastric tube (NGT) connected to intermittent suction, which task can be assigned to the unlicensed assistive personnel (UAP)?