Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

Answer and Explanation

The Correct Answer is []

Condition: Elder maltreatment 2 actions: Initiate a referral to adult protective services; Administer prescribed pain medication 2 parameters: Frequency and severity of bruises; Nutritional intake and weight

Rationale for correct condition The client’s physical signs (multiple bruises in various stages, unclean appearance), social indicators (dependency, financial control, food insecurity), and behavioral changes in the presence of the caregiver strongly suggest elder abuse. Elder maltreatment includes physical, emotional, financial, and neglectful harm. An 82-year-old with a BMI of 18.3 shows undernutrition. His improved demeanor away from the child reflects psychological coercion. Bruises in different stages may indicate repeated trauma over time.

Rationale for correct actions Referral to adult protective services ensures legal and social intervention and facilitates multidisciplinary evaluation for safety. Reporting is mandated and protects the client from further harm. Administering pain medication addresses acute injury (fracture of right radius) and helps restore comfort. Effective pain management is crucial for mobility and assessment of additional injuries.

Rationale for correct parameters Monitoring bruising patterns helps identify ongoing abuse and quantify recovery or new trauma. Repeated injuries in various healing stages are hallmark signs. Nutritional intake and weight reflect neglect; insufficient food intake leads to weight loss and reduced immune function. Tracking BMI and calorie intake can guide long-term recovery and support.

Rationale for incorrect conditions Osteoporosis-related fracture would more likely occur with minimal trauma and does not explain social neglect or emotional signs. Accidental fall may be plausible but lacks explanation for systemic neglect and coercion. Peripheral neuropathy doesn’t explain acute arm pain or psychosocial signs of neglect.

Rationale for incorrect actions Encouraging activity is inappropriate during acute fracture recovery and potential abuse. Bone density scans assess fragility but don’t address safety risks. Nutritional supplements may help but don’t resolve underlying maltreatment or acute injury.

Rationale for incorrect parameters Bone density is not immediately relevant and doesn't reflect maltreatment. Blood pressure fluctuations are not present and don’t indicate abuse. Grip strength cannot be assessed accurately with an arm fracture and isn't useful for abuse evaluation.

Take-home points • Elder maltreatment includes physical harm, neglect, emotional abuse, and financial exploitation • Victims may show improved responsiveness when abuser is absent • Multidisciplinary intervention via adult protective services is critical • Differentiation from accidental injury ensures proper protection and care

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Correct Answer is B

Explanation

Choice A rationale

Sitting in chairs with low, soft backs can worsen osteoarthritis symptoms and increase joint stress. Low chairs require more force from the hips and knees to stand up, which can strain these joints. Soft backs provide inadequate support, leading to poor posture and increased stress on the spine and other joints. Proper joint protection involves maintaining good posture and minimizing strain on affected joints.

Choice B rationale

Using both hands to hold objects distributes the weight and stress evenly across multiple joints, such as those in both wrists and hands, thereby reducing the workload on any single joint. This technique minimizes the risk of joint deformation and pain associated with osteoarthritis by preventing excessive force from being applied to a single joint, a key principle of joint protection.

Choice C rationale

Pushing up from a bed with fingers puts a concentrated, high-impact force on the small joints of the fingers, which are often affected by osteoarthritis. This action can lead to pain, inflammation, and potential deformity over time. Instead, individuals should use their palms or forearms to push up, distributing the force over a larger, stronger surface area.

Choice D rationale

Turning doorknobs clockwise or in any specific direction with a forceful grip can exacerbate joint pain and strain in the fingers and wrist. This motion places significant torque on the affected joints. To protect joints, clients should be advised to use lever-style doorknobs or adaptive devices that require less grip strength and a different motion. *.

A. Ketonuria. B. Warm skin. C. Nervousness. D. Tachypnea.

Correct Answer is C

Explanation

Choice A rationale

Ketonuria, the presence of ketones in the urine, is typically associated with hyperglycemia and diabetic ketoacidosis. When glucose levels are high and cells can't use it for energy, the body starts breaking down fats, producing ketones as a byproduct. A blood glucose reading of 64 mg/dL is low and indicates hypoglycemia, not hyperglycemia.

Choice B rationale

Warm skin is a sign of vasodilation, often associated with a fever or an inflammatory response. In the context of hypoglycemia, the sympathetic nervous system is activated, leading to vasoconstriction, which would typically cause the skin to feel cool and clammy, not warm.

Choice C rationale

Nervousness is a common symptom of hypoglycemia. When blood glucose levels drop, the body releases counterregulatory hormones like epinephrine and norepinephrine from the adrenal glands. This sympathetic nervous system activation causes symptoms such as nervousness, anxiety, palpitations, and tremors as the body attempts to raise blood sugar.

Choice D rationale

Tachypnea, or rapid breathing, is a clinical finding associated with metabolic acidosis, such as diabetic ketoacidosis (DKA). In DKA, the body tries to compensate for the high acid load by increasing the respiratory rate to blow off carbon dioxide. It is not a typical symptom of hypoglycemia, which is indicated by a reading of 64 mg/dL. .

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Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has osteoarthritis about joint protection strategies. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

A nurse performs a capillary blood glucose check for a client who has type 1 diabetes mellitus and obtains a reading of 64 mg/dL on the glucometer. Which of the following assessment findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is part of a task force planning to audit a facility's nursing units concerning adherence to hand-hygiene protocols. Which of the following steps should the task force take first.

A nurse is caring for a client who has deep-vein thrombosis and a new prescription for antiembolic stockings. Which of the following actions should the nurse take?

A nurse is reviewing the medical record of a client who has a prescription for misoprostol for induction of labor. Which of the following findings is a contraindication for administration of this medication?

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take first?

The nurse should first address the client’s dropdown followed by the client’s dropdown.

A nurse is caring for a group of clients and identifying what tasks she can delegate to an assistive personnel (AP). Which of the following tasks should the nurse delegate to an AP?

A nurse is preparing regular and NPH insulin in the same syringe for a client who has diabetes mellitus. Which of the following actions should the nurse take?