An older adult client who reports pain in the arms and back is brought to the emergency department (ED) by an adult child who states the client "fell out of a chair." The nurse notes that the client has been in the ED five times in the last year for a variety of superficial injuries. Which nursing action has the highest priority?

Request social services to make a home visit.

Interview the client privately without the adult child present.

Complete a neurological and musculoskeletal assessment.

Ask the client if an assisted living facility is an option for safety concerns.

Answer and Explanation

The Correct Answer is B

A. Request social services to make a home visit. This is important but not the immediate priority. It can be part of the long-term intervention plan once the immediate safety and health of the client are ensured.

B. Interview the client privately without the adult child present. This is the highest priority. It allows the nurse to assess for potential abuse or neglect without the influence or intimidation of the accompanying adult, ensuring the client can speak freely.

C. Complete a neurological and musculoskeletal assessment. This is important to assess the extent of the injuries and the client's overall physical health, but it follows the immediate need to ensure the client's safety and ability to speak freely about their situation.

D. Ask the client if an assisted living facility is an option for safety concerns. While exploring living arrangements is important for long-term safety, it is not the highest priority. Ensuring the client's immediate safety and obtaining accurate information about their situation takes precedence.

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Correct Answer is D

Explanation

A. Dimpled area above anus: This can be a sign of a pilonidal cyst, a condition where hair follicles become embedded under the skin.

B. Flap of tissue at sphincter: This could indicate haemorrhoids, swollen veins in the anus and rectum.

C. Hypotonic tone of the anal sphincter: Weak anal sphincter tone can lead to faecal incontinence.

D. Increased pigmentation and coarse skin: This is a normal finding, especially in adults. The perianal area can have a darker colour and thicker skin texture compared to other areas

A. 3-year-old preferring to walk on the tip toes. B. 1.5-year-old attempting to scribble on paper. C. 5-month-old with use of whole hand grasp. D. 3.5-month-old with diminished Moro reflex.

Correct Answer is D

Explanation

A. 3-year-old walking on tiptoes: While some children may walk on their tiptoes occasionally, it's not necessarily a cause for concern unless it's persistent or accompanied by other developmental delays.

B. 1.5-year-old attempting to scribble: This is a typical stage for exploring hand and finger movements, leading to early attempts at drawing.

C. 5-month-old with whole hand grasp: At this age, infants use their whole hand to grasp objects, which is a normal developmental step before developing a more refined pincer grasp.

D. 3.5-month-old with diminished Moro reflex. The Moro reflex is a normal reflex in newborns that typically disappears by around 4 to 6 months of age. A diminished or absent Moro reflex before this age could indicate neurological concerns or developmental delays. Referral to a healthcare provider is necessary for further evaluation.

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Naxlex Comprehensive Predictor Exams

While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perianal area and anus. Which findings indicate a normal appearance of the anus?

Correct Answer is D

Explanation

A clinic nurse is assessing infants and toddlers for fine and gross motor development. Which child should the nurse refer to a healthcare provider for further evaluation?

Correct Answer is D

Explanation

In assessing a male client's level of consciousness, the nurse determines that the client does not open his eyes spontaneously. Which should the nurse do next?

To compare arterial circulation in a client's lower extremities, which assessment should the nurse complete?

The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?

In auscultating for the presence of a carotid artery bruit, the nurse places the bell of the stethoscope at which location?

Which is the best approach for the nurse to use when interviewing a client about alcohol and substance use?

When performing a neurologic assessment on an alert client, the nurse observes that the client's pupils are both round, 3 mm in size, and respond briskly to light. Which notation should the nurse use when documenting the assessment?

A client reports episodes of syncope. Which assessment finding should the nurse anticipate?