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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. "What were you doing when you first noticed the problem?"

This question helps to identify any specific activities or events that may have triggered the onset of back pain. Understanding the circumstances surrounding the pain can provide valuable information about its potential cause.

B. "Have you taken any medications to relieve the pain?"

While it's important to assess if the adolescent has taken any medications, such as over-the-counter pain relievers, to manage the pain, this question may not be the most immediate priority. It's essential to first gather information about the nature and onset of the pain to guide further assessment and management.

C. "Do you remember ever having this type of pain in the past?"

This question helps to determine if the adolescent has a history of similar back pain episodes. Past episodes of back pain can provide insight into potential underlying conditions or recurrent issues that may be contributing to the current complaint.

D. "Does changing your position make the pain worse?"

This question is crucial in assessing the characteristics of the pain and its response to movement or positional changes. It can help differentiate between musculoskeletal causes of back pain, which may worsen with movement, and other potential causes.

A. Assess subconjunctival color for pallor B. Review serum creatinine results. C. No additional assessment needed. D. Obtain every 2-hour blood pressure readings.

Correct Answer is C

Explanation

A. Assess subconjunctival colour for pallor. Subconjunctival colour assessment is not directly related to hyperpigmented freckles and is not typically indicated in this scenario.

B. Review serum creatinine results. Serum creatinine levels are not directly related to hyperpigmented freckles unless there are specific concerns about kidney function, which are not mentioned in the scenario.

C. No additional assessment needed. Hyperpigmented freckles are common benign skin findings in older adults and do not typically require further assessment unless there are other concerning symptoms or lesions present.

D. Obtain every 2-hour blood pressure readings. Blood pressure monitoring at such frequent intervals is not indicated based solely on the presence of hyperpigmented freckles.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The school nurse is interviewing an adolescent who wants to go home from school because of "back pain." Which question should the nurse ask first?

Correct Answer is A

Explanation

While assessing the skin on an older adult client, the nurse notices hyperpigmented freckles on the client's hands and arms. Which additional nursing assessments are indicated?

Correct Answer is C

Explanation

Which method is best for the nurse to use in determining early development of ascites?

The nurse completes percussion of the abdomen on an adult client. Which finding is considered normal?

The nurse hears crackles when auscultating a client's lung sounds. Which is an accurate description of the sound of crackles?

When inspecting the client's skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client's history requires additional follow-up by the nurse?

The nurse is conducting a functional assessment on an older adult client who is reporting decreased activity due to reduced energy and strength. Which action should the nurse perform during the functional assessment?

Which assessment technique should the nurse use to confirm the presence of papilledema in a client with a rapidly decreasing level of consciousness?

When assessing a client's skin, which finding should the nurse report to the healthcare provider?

The nurse inspects the client's fingernails. Which differentiating characteristics are observed in this assessment finding?