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Depression or withdrawn behavior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Depression or withdrawn behaviour: This behavior is often seen in neglected elders who lack meaningful interaction, care, or stimulation.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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Free Nursing Study Resources

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

Explanation

Rationale:

Count the respirations: Lorazepam is a benzodiazepine that can cause respiratory depression, especially when given IV. Regular monitoring of respiratory rate helps detect hypoventilation early.
Listen for heart palpitations: While the client initially had atrial tachycardia, monitoring palpitations is not a priority in evaluating lorazepam’s effectiveness, which focuses more on CNS and respiratory status.
Assess for constipation: Constipation is not an acute or common side effect associated with single-dose IV lorazepam. It is not relevant in short-term monitoring.
Evaluate client for motor coordination: Benzodiazepines like lorazepam may impair psychomotor function. Assessing coordination can help monitor CNS depressant effects and safety.
Observe level of consciousness: Altered LOC is a common side effect of lorazepam due to its sedative properties. Ongoing neurological checks are essential.
Monitor for drowsiness: Drowsiness is a common and expected effect of lorazepam. Monitoring helps determine if the sedative effect is appropriate or excessive.

A. "Are you the type of person who shares your problems easily?" B. "What do you think is your primary goal to achieve this time?" C. "Would you like me to sit with you for a while?" D. "Have you experienced changes in your life recently?"

Correct Answer is C

Explanation

Rationale:

A. "Are you the type of person who shares your problems easily?": This question explores communication style but may feel invasive or irrelevant to someone in acute distress. It does not directly address the client’s current emotional needs or offer support.

B. "What do you think is your primary goal to achieve this time?": Goal setting is important during the planning phase of care, but clients in overwhelming anxiety may not be ready for structured thinking. This question may increase pressure and exacerbate anxiety.

C. "Would you like me to sit with you for a while?": This offers immediate emotional support and conveys presence, which helps build trust and reduce anxiety. It is a therapeutic approach that meets the client’s most urgent need for calm and reassurance.

D. "Have you experienced changes in your life recently?": Life changes may contribute to anxiety, but exploring them is appropriate after the client feels emotionally safe and stable. The initial priority is to establish a calming presence, not to probe background stressors.

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Focused Assessment Area	Clinical Finding
Musculoskeletal	Ambulates with a walker Flaccidity of left arm Passive range of motion of the left leg
Psychosocial	Fits of laughter Angry outbursts Tearful sharing of stories
Neurological	Drinks with repetitive cough Decorticate posturing Speaks in short sentences

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

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.

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

Explanation

The nurse is assessing a client who is experiencing overwhelming anxiety and difficulty performing self-care. Which question should the nurse ask first?

Correct Answer is C

Explanation

The nurse is conducting a visual screening of a group of older adults. Which finding should the nurse report to the healthcare provider immediately?

When entering the room of a sedated postoperative client, which assessment requires immediate intervention by the nurse?

Which dietary intervention(s) should the nurse include in the plan of care for a client who had bariatric surgery? Select all that apply.

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.

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.