Which older adult on bed rest is most at risk to develop skin breakdown? A client who:.

Applies powder after drying the skin.

Has been NPO for four days.

Bathes twice a week.

Has hypertension.

Answer and Explanation

The Correct Answer is B

A client who has been NPO for four days is most at risk to develop skin breakdown. This is because being NPO (nothing by mouth) can lead

to malnutrition and dehydration, which are both risk factors for bedsores. Malnutrition can impair the skin’s ability to heal and resist infection, while dehydration can make the skin dry and fragile.

Choice A is wrong because applying powder after drying the skin can help prevent moisture and friction, which are also risk factors for bedsores.

Choice C is wrong because bathing twice a week may not be frequent enough to keep the skin clean and free of irritants, which can also contribute to bedsores.

Choice D is wrong because hypertension (high blood pressure) does not directly cause bedsores, although it may be associated with other conditions that affect blood circulation and tissue oxygenation.

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Correct Answer is A

Explanation

This is because the patient may be experiencing serotonin toxicity, a potentially life- threatening condition caused by excessive levels of serotonin in the brain. Paroxetine (Paxil) is a selective serotonin reuptake inhibitor (SSRI) that increases serotonin levels, and some other medications or supplements may interact with it and cause serotonin toxicity. Some of the symptoms of serotonin toxicity include agitation, increased sweating, and hallucinations.

Choice B is wrong because administering an anti-anxiety medication may worsen serotonin toxicity, especially if the medication is also an SSRI or another serotonergic agent.

Choice C is wrong because placing the patient in loose bilateral arm restraints may increase the risk of injury or agitation, and does not address the underlying cause of the symptoms.

Choice D is wrong because telling the patient that the voices they are hearing are not real may not be helpful or reassuring, and may also increase the patient’s distress or confusion.

A. Tarry-colored stools. B. Swelling of the leg and knee. C. Right upper quadrant discomfort. D. Bruising around the injured knee.

Correct Answer is A

Explanation

This is because aspirin can cause gastrointestinal bleeding, ulceration, and perforation as side effects. Tarry-colored stools indicate the presence of blood in the stool, which is a sign of bleeding in the upper gastrointestinal tract.

This is a serious condition that requires immediate medical attention.

Choice B. Swelling of the leg and knee is wrong because it is not related to aspirin use.

It may indicate inflammation, infection, or injury of the leg and knee, but it is not a priority symptom to report to the HCP.

Choice C. Right upper quadrant discomfort is wrong because it is not related to aspirin use.

It may indicate liver or gallbladder problems, but it is not a priority symptom to report to the HCP.

Choice D. Bruising around the injured knee is wrong because it is not related to aspirin use.

It may indicate trauma, bleeding disorders, or coagulation problems, but it is not a priority symptom to report to the HCP.

Normal ranges for bleeding time are 2 to 7 minutes. Normal ranges for PTT are 25 to 35 seconds. Normal ranges for liver enzymes are AST 10 to 40 U/L and ALT 7 to 56 U/L.

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Which older adult on bed rest is most at risk to develop skin breakdown? A client who:.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client taking paroxetine (Paxil) presents to the emergency room with agitation, increased sweating, and new auditory hallucinations. What is the priority action?

Correct Answer is A

Explanation

A client has been taking aspirin 325 mg six to eight times a day for the past two weeks to control pain from a knee injury. Which symptom reported by the client should the nurse report to the health care provider (HCP) for priority follow-up?

Correct Answer is A

Explanation

Which statement made by a client taking nitroglycerin as needed (prn) indicates understanding of the instructions for safe use of this drug?

A client is being educated about insulin and is able to repeat the newly acquired information using their own words to the nurse. Which of the following statements confirm the teaching has been effective?

Which action should the nurse take after assessing a 2-day-old wound that has a crust along the edges, is red and appears slightly swollen?

A 68-year-old client diagnosed with cataracts should be assessed for which finding?

The nurse observes the unlicensed assistive personnel (UAP) obtain vital signs on four adult clients. For which client should the nurse intervene to redirect to use of proper method?

The health care provider orders a trough level of an antibiotic administered every twenty four hours. When should the nurse plan for a trough level to be drawn?

Which statement provides the best documentation of the amount of wound drainage?

A client in the emergency department who has been raped says repeatedly, “if only I hadn’t worn that sexy dress.” Which response by a nurse is appropriate?