Exhibits

The nurse suspects elder mistreatment.
Click to indicate if the listed manifestation of abuse is consistent with physical abuse, abandonment, or neglect. Each row must have only one response option selected.

Leaving an older adult in a public space

Depression or withdrawn behavior

Poor personal hygiene

Bruises in various stages of healing

Untreated pressure injuries

Over sedation

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"A"}}

1.   Leaving an older adult in a public space
o   Abandonment
Leaving an older adult alone in a public space indicates abandonment, where the caregiver has left the person without appropriate supervision or care.
2.   Depression or withdrawn behavior
o   Neglect
Changes in mood, such as depression or withdrawn behavior, can be signs of neglect where the caregiver fails to provide emotional support or engage with the older adult.
3.   Poor personal hygiene
o   Neglect
Poor personal hygiene, such as the client wearing only incontinence briefs, is a sign of neglect. It reflects a lack of attention to the client's basic care needs.
4.   Bruises in various stages of healing
o   Physical Abuse
Bruises in different stages of healing can be signs of physical abuse. It indicates potential harm or violence inflicted on the older adult.
5.   Untreated pressure injuries
o   Neglect
Untreated pressure injuries indicate neglect, as it shows a failure to address the client’s physical care needs and prevent complications from prolonged immobility.
6.   Over sedation
o   Physical Abuse
Over sedation can be a form of physical abuse where the caregiver might administer excessive medication to control or subdue the older adult.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A. Intensifying headache: An intensifying headache could indicate increased intracranial pressure or progression of the tumor. This is a potentially life-threatening symptom that requires immediate attention from the healthcare provider.
B. Right ear hearing loss: Hearing loss is a common symptom of acoustic neuroma but is not life-threatening on its own. It should be monitored but is not an urgent concern.
C. Difficulty with balance: Balance issues are related to the acoustic neuroma’s impact on the vestibular system. While concerning, it is not immediately life-threatening compared to symptoms indicating increased intracranial pressure.
D. Facial numbness: Facial numbness can occur with an acoustic neuroma due to pressure on facial nerves, but it is not typically an immediate life-threatening concern compared to signs of increased intracranial pressure.

A. Document the findings in the electronic medical record. B. Test the fluid on the dressing for glucose. C. Mark the drainage area with a pen and continue to monitor. D. Change the dressing using a compression bandage.

Correct Answer is B

Explanation

A. Documenting the findings is important for record-keeping but is not the immediate priority. The presence of clear fluid could indicate cerebrospinal fluid (CSF) leakage, which requires immediate assessment.
B. Testing the fluid on the dressing for glucose is the most critical action. CSF is high in glucose, so this test helps determine if the clear fluid is indeed CSF, which is a significant postoperative complication requiring immediate intervention.
C. Marking the drainage area and continuing to monitor is not sufficient in the face of potential CSF leakage. Immediate action is needed to confirm the nature of the fluid.
D. Changing the dressing with a compression bandage may be necessary, but the immediate priority is to confirm whether the fluid is CSF before taking further steps.

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Exhibits The nurse suspects elder mistreatment. Click to indicate if the listed manifestation of abuse is consistent with physical abuse, abandonment, or neglect. Each row must have only one response option selected.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing a client with an acoustic neuroma for a magnetic resonance image (MRI). Which client complaint is life-threatening and should be reported to the healthcare provider immediately?

Correct Answer is A

Explanation

The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. Which action should the nurse implement immediately?

Correct Answer is B

Explanation

A client is admitted for an exacerbation of heart failure (HF) and is being treated with diuretics for fluid volume excess. In planning nursing care, what intervention(s) should the nurse include? Select all that apply.

A client who is hypotensive is receiving dopamine, an adrenergic agonist, intravenously (IV) at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

Case 2/6 Exhibits The nurse suspects elder mistreatment. Click to indicate if the listed manifestation of abuse is consistent with physical abuse, abandonment, or neglect. Each row must have only one response option selected.

A client on the mental health unit has been scowling and rapidly pacing up and down the hall for several minutes. Which behaviors are most important for the nurse to monitor?

A client with a history of adrenal insufficiency is admitted to the intensive care unit with an acute adrenal crisis. The client is complaining of nausea and joint pain. Exhibits Which intervention should the nurse implement first?

Exhibits

The nurse suspects elder mistreatment.
Click to indicate if the listed manifestation of abuse is consistent with physical abuse, abandonment, or neglect. Each row must have only one response option selected.