Patient Data

Exhibits

Click to indicate if the listed manifestations of abuse is consistent with physical abuse, abandonment, or neglect. Each row must have only one response option selected.

Depression or withdrawn behavior

Oversedation

Untreated pressure injuries

Bruises in various stages of healing

Poor personal hygiene

Leaving an older adult in a public space

Answer and Explanation

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

Rationale:

Depression or withdrawn behaviour: This behavior is often seen in neglected elders who lack meaningful interaction, care, or stimulation. Emotional neglect and isolation can lead to signs of withdrawal and sadness.
Oversedation : Overmedicating a client to control behavior or suppress activity is considered physical abuse. It reflects intentional harm or misuse of medications, especially when used to subdue.
Untreated pressure injuries: Failure to address and treat pressure ulcers indicates neglect, especially when the wounds are visible and advanced. It shows a lack of basic caregiving and health maintenance.
Bruises in various stages of healing: Multiple bruises at different stages suggest repeated physical trauma over time. This is a strong red flag for physical abuse rather than accidental injury.
Poor personal hygiene: Long, dirty nails and unclean conditions point to inadequate caregiving. Basic hygiene neglect often reflects poor or absent daily care practices.
Leaving an older adult in a public space: Leaving an elder alone in public with no supervision or support meets the definition of abandonment. It places the individual in a vulnerable and unsafe situation.

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Correct Answer is A

Explanation

Rationale:

A. Remind the UAP to apply a fitted respirator mask before entering the client's room:
Neisseria meningitidis is transmitted via respiratory droplets, and clients require droplet precautions. A fitted respirator mask is necessary when within 3 feet of the client.

B. Assign the UAP to provide care for another client and assume full care of the client:
Delegating tasks based on infection risk may be reasonable, but it's not necessary to reassign care if the UAP follows proper precautions.

C. Review the need for the UAP to wear a face mask while in close contact with the client: Education is essential but does not take priority over preventing immediate exposure. Ensuring protective equipment is worn first is more urgent than providing background instruction.

D. Instruct the UAP to notify the nurse of any changes in the client's emesis: Monitoring emesis is part of ongoing care but is not as urgent as preventing transmission of a highly contagious illness. Infection control measures must be enforced before other instructions.

A. Consider having the teen's caregiver wait in the clinic reception area. B. Encourage the adolescent to handle the physical exam instruments. C. Allow time for talking before beginning the physical assessment. D. Familiarize the adolescent with the clinic setting and healthcare staff. E. Make every effort to establish eye contact with the adolescent.

Correct Answer is ["B","C","D"]

Explanation

Rationale:
A. Consider having the teen's caregiver wait in the clinic reception area: Adolescents with ASD may experience heightened anxiety in unfamiliar environments. Having their caregiver nearby can offer a sense of security and comfort, making the experience less overwhelming.

B. Encourage the adolescent to handle the physical exam instruments: Allowing the adolescent to touch and explore the equipment before use helps reduce sensory-related anxiety. It also increases cooperation by promoting a sense of predictability and control.

C. Allow time for talking before beginning the physical assessment: Taking time to communicate and build rapport before initiating the assessment helps reduce anxiety and fosters trust. Many adolescents with ASD need more time to process information and adjust to new interactions.

D. Familiarize the adolescent with the clinic setting and healthcare staff: Gradual exposure to the physical space and people helps reduce sensory overload and builds comfort with the environment. Structured familiarity can prevent overstimulation and improve cooperation.

E. Make every effort to establish eye contact with the adolescent: Insisting on eye contact can increase distress, as many individuals with ASD find direct eye contact uncomfortable or overwhelming. Respecting their communication style is more effective than imposing neurotypical expectations.

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Patient Data Exhibits Click to indicate if the listed manifestations 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

A client with Neisseria meningitidis calls the nurses station to report a severe headache and vomiting. The unlicensed assistive personnel (UAP) approaches the room to provide an emesis basin and is stopped by the nurse. Which action should the nurse take?

Correct Answer is A

Explanation

An adolescent with autism spectrum disorder (ASD) comes to the clinic for the first time. Which intervention(s) should the nurse implement? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

Patient Data Exhibits For each action, identify if it is indicated or not indicated when monitoring the effects of lorazepam administration. Each row must have one response action selected.

Which long-term outcome is most important for the nurse to include in the plan of care for an older adult client with chronic pyelonephritis?

A client receives a prescription for 1 L of lactated Ringer's IV to be infused over 12 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

A client shares with the nurse concerns of a possible stomach ulcer. The client is experiencing heartburn and a dull gnawing pain that is relieved with eating. Which is the best response by the nurse?

Patient Data

Exhibits

Click to indicate if the listed manifestations of abuse is consistent with physical abuse, abandonment, or neglect. Each row must have only one response option selected.