Nokea
The home health nurse is caring for a 75-year-old client with dementia and suspects that the client may be experiencing elder mistreatment. Which of the following findings would be consistent with elder mistreatment? Select all that apply.
- A. disorientation to time and place
- B. stage 2 pressure injury on the sacrum
- C. 15-lb (6.8-kg) weight loss over the past 4 weeks
- D. eyeglasses are broken and have been unusable for 2 months
- E. prescription medications are expired and have not been refilled
Correct Answer: B,C,D,E
Rationale: Pressure injuries, significant weight loss, broken eyeglasses, and expired medications suggest neglect or mistreatment. Disorientation is expected in dementia.
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A 4-year old is scheduled for a routine tonsillectomy. Which of the following lab findings should be reported to the doctor?
- A. A hemoglobin of $12 \mathrm{gm}$
- B. A platelet count of $200,000 \mathrm{cu} \mathrm{mm}$
- C. A white cell count of $16,000 \mathrm{cu} \mathrm{mm}$
- D. A urine specific gravity of 1.010
Correct Answer: C
Rationale: A white cell count of 16,000 is elevated, suggesting infection, which must be reported before surgery. Hemoglobin , platelets , and urine specific gravity are normal.
A client with a history of renal calculi passes a stone made up of calcium oxalate. Which of the following diet instructions should be given to the client?
- A. Increase intake of meats, eggs, fish, plums, and cranberries.
- B. Avoid citrus fruits and juices.
- C. Avoid dark green, leafy vegetables.
- D. Increase intake of dairy products.
Correct Answer: C
Rationale: Dark green, leafy vegetables are high in oxalates, which contribute to calcium oxalate stones. Meats and dairy increase other stone types, and citrus juices are beneficial.
In the past 12-month period, a man has been arrested twice for driving while intoxicated. He is able to perform his activities of daily living without the use of alcohol and restricts his drinking to weekends. This client meets the criteria for which of the following?
- A. Alcohol withdrawal syndrome
- B. Bad judgment syndrome
- C. Substance abuse
- D. Substance dependence
Correct Answer: C
Rationale: Repeated legal issues from weekend drinking indicate substance abuse, as it causes significant impairment without daily dependence.
Which of the following musical instruments is best for a teen with asthma?
- A. Guitar
- B. Piano
- C. Drums
- D. Clarinet
Correct Answer: A
Rationale: The guitar does not require breath control, making it suitable for a teen with asthma, unlike wind instruments like the clarinet.
In order to enhance a client's response to medication for chest pain from acute angina, the nurse should emphasize
- A. Learning relaxation techniques
- B. Limiting alcohol use
- C. Eating smaller meals
- D. Avoiding passive smoke
Correct Answer: A
Rationale: Learning relaxation techniques. Reducing anxiety through relaxation enhances the effectiveness of pain medication for angina.