An older client who lives with a caregiver is admitted to an emergency department with a fractured arm. The client is soaked in urine and has dried fecal matter on lower extremities. The client is 6 feet tall and weighs 120 pounds. Which condition would the nurse suspect?

Abuse and/or neglect

Caregiver role strain

Inability of the client to meet self-care needs

Alzheimer's disease

Answer and Explanation

The Correct Answer is A

A. Abuse and/or neglect is the most likely concern in this situation. The fact that the client has a fractured arm, is soaked in urine, and has dried fecal matter on their lower extremities suggests neglect. The client's physical appearance and hygiene issues point to a lack of appropriate care or supervision. This requires further investigation to ensure the safety of the client.
B. Caregiver role strain can lead to stress and burnout, but it doesn't necessarily explain the physical neglect, including the broken arm and unsanitary condition. This could still be a contributing factor but is not the most likely primary concern.
C. Inability of the client to meet self-care needs could contribute to hygiene issues, but it does not explain the fracture and the overall neglect of care. Inadequate self-care ability might occur with conditions like dementia, but the neglect aspect points more to external factors.
D. Alzheimer's disease may cause cognitive decline and difficulty with self-care, but it doesn't directly explain the neglect or lack of proper hygiene or injury care. It’s more likely a factor in a situation of neglect, rather than the sole cause.

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Correct Answer is C

Explanation

A. Restricting fluid intake is not necessary for a patient with neutropenia. In fact, maintaining adequate hydration is essential, especially when managing the effects of chemotherapy.
B. Inserting an indwelling urinary catheter increases the risk of infection and should only be done when absolutely necessary, especially in patients with neutropenia who are at increased risk of infections.
C. Neutropenic patients have a decreased ability to fight infections, so it is crucial to restrict visitors who have communicable illnesses to prevent the patient from becoming infected.
D. Hand hygiene is essential, and gloves should not replace proper hand washing. The nurse should wash hands before and after patient contact to prevent infection, not simply wear gloves.

A. Statement regarding outlook on living B. Statement related to feelings of sadness and anger. C. Knowledge of expectations during group meetings. D. Awareness of the therapist's role. E. Statement related to use of pharmacological interventions

Correct Answer is ["A","E"]

Explanation

A. Statement regarding outlook on living is a priority concern because the client stated, "I can't go on living without my child." This indicates possible suicidal ideation and requires immediate assessment and intervention for client safety.
B. Statement related to feelings of sadness and anger is an expected reaction in the grieving process. While it should be monitored, it is not an immediate safety risk and therefore not the top priority.
C. Knowledge of expectations during group meetings is related to participation in therapy, not a pressing concern that threatens the client’s wellbeing.
D. Awareness of the therapist's role shows insight and is helpful for therapy engagement, but is not urgent.
E. Statement related to use of pharmacological interventions is a priority because the client reports non-adherence to prescribed Sertraline due to a belief it won’t help. Noncompliance with medication can worsen depression and increase suicide risk, making this a key issue to address immediately.

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An older client who lives with a caregiver is admitted to an emergency department with a fractured arm. The client is soaked in urine and has dried fecal matter on lower extremities. The client is 6 feet tall and weighs 120 pounds. Which condition would the nurse suspect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with leukemia who is experiencing neutropenia as a result of chemotherapy. Which action should the nurse include in the plan of care for this patient?

Correct Answer is C

Explanation

A nurse in a mental health clinic is caring for a client who is grieving. Exhibits A nurse is caring for a client who is grieving. Which of the following findings should the nurse identify as a priority to address?Select all that apply.

Correct Answer is ["A","E"]

Explanation

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