During a community health screening fair for older adults, a nurse notices a client with pale, bluish feet and sores on both lower extremities that are healing poorly.
What should the nurse’s intervention be?
Instruct the client to apply antibiotic ointment to the sores.
Create a list of foods that promote wound healing.
Refer the client to a healthcare provider for a complete evaluation.
Send the client to the emergency department for treatment.
The Correct Answer is C
Answer and explanation The correct answer is C. Choice A rationale
While applying antibiotic ointment to the sores might help prevent infection, it does not address the underlying issue causing the sores and poor healing.
Choice B rationale
Although a diet rich in nutrients can promote wound healing, it is not the most immediate need for this client. The client’s symptoms suggest a serious underlying condition that requires medical evaluation.
Choice C rationale
The client’s symptoms of pale, bluish feet and sores on both lower extremities that are healing poorly suggest a severe and untreated medical condition, possibly related to circulation or skin integrity. Therefore, the nurse should refer the client to a healthcare provider for a complete evaluation.
Choice D rationale
Sending the client to the emergency department for treatment might be necessary in some cases, but it is more appropriate to first refer the client to a healthcare provider for a complete evaluation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Answer and explanation The correct answer is D. Choice A rationale
Giving a complete bed bath to further assess the client may not be the most appropriate intervention in this case. The client is semi-conscious and cries out in pain when turned or moved. A complete bed bath could potentially cause unnecessary discomfort and distress.
Choice B rationale
Removing the fentanyl patch as directed by prescription may not be the best course of action. Fentanyl is a powerful opioid used to manage severe pain. The client’s parents report that their child cries out in pain when turned or moved, suggesting that the client is experiencing significant pain. Removing the fentanyl patch could potentially exacerbate the client’s pain.
Choice C rationale
Calling for ambulance transportation to the hospital immediately may not be necessary at this time. The client’s vital signs are stable, and there is no indication of an immediate medical emergency based on the information provided.
Choice D rationale
Discussing end-of-life decisions with the client’s parents is the most appropriate intervention. The client is semi-conscious, sleeps most of the time, and is in significant pain. These symptoms suggest that the client’s condition is deteriorating. It is important to have conversations about end-of-life care preferences and decisions to ensure that the client’s wishes are respected and that the parents are prepared.
Correct Answer is B
Explanation
Answer and explanation
The correct answer is Choice B.
Choice A rationale
The Social Security Administration office primarily provides financial support to retirees, disabled individuals, and families of deceased workers. While it might provide some financial assistance to the client, it does not directly address the client’s nutritional needs or potential social isolation.
Choice B rationale
The Senior Citizen Center offers a variety of services to older adults, including meal programs, health and wellness programs, and opportunities for social interaction. This could help address the client’s weight loss and potential social isolation.
Choice C rationale
The Women, Infants, and Children office provides nutritional support to low-income pregnant women, new mothers, and young children. It is not typically a resource for older adults.
Choice D rationale
The Adult Day Care Center provides care and companionship for older adults who need assistance or supervision during the day. While it could provide social interaction for the client, it does not directly address the client’s weight loss.
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