During a nursing home visit, the son notices multiple healing bruises

Care of Older Adults NCLEX Questions

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Question 1 of 5.

During a nursing home visit, the son notices multiple healing bruises on his father's arms and legs and calls a friend who is a nurse. Which initial recommendations should the nurse provide to the son? Select all that apply.

A. Ask your father how the bruises occurred and whether he was abused.'

B. Contact Adult Protective Services immediately to report the abuse.'

C. Verify with the nursing staff whether your father is on anticoagulants.'

D. Inform the agency's nursing supervisor that your father is being abused.'

E. Contact the state ombudsman who can help you make an anonymous report.'

Explanation: Asking about bruise causes and checking for anticoagulants (which cause bruising) are initial steps. Reporting abuse or contacting authorities requires more evidence.

Question 2 of 5.

The unsteady 20S-year-old client persists in ambulating to the bathroom alone despite being reminded to call for assistance. The nurse concludes that, according to Havighurst's developmental tasks, this behavior reflects which need of the client?

A. Adjusting to physiological changes

B. Independence

C. Industry

D. Integrity

Explanation: The client is attempting to perform self-care and to demonstrate the ability to be self-sufficient and independent from other adults. Adjusting to physiological changes is a developmental task of middle age. Industry and integrity are Erikson's tasks, not Havighurst's, and apply to different age groups.

Question 3 of 5.

The nurse is assessing the chest of the normally healthy adult male client without chest abnormalities. Which chest curvature illustrated should the nurse expect to observe?

A. Illustration A

B. Illustration B

C. Illustration C

D. Illustration D

Explanation: The normal adult chest has an anteroposterior-to-lateral ratio of approximately 1:2 and a costal angle less than 90 degrees. Illustration A is pectus excavatum, B is pectus carinatum, and D is barrel chest associated with COPD.

Question 4 of 5.

The 18 year-old tells the clinic nurse, 'Thinking about college is stressing me out. I am used to getting A's and B's.' Which statement should the nurse reserve until a follow-up visit with the client?

A. Expressing your feelings of anxiety to a friend or nurse helps you cope emotionally.'

B. I will check with the provider about prescribing paroxetine hydrochloride.'

C. Exercise increases the release of endorphins and can enhance your sense of well-being.'

D. If you like drawing or painting, register for an art class during your first semester in college.'

Explanation: The nurse should reserve suggesting an antidepressant until other interventions have been tried. Paroxetine influences neurotransmitters related to anxiety, but non-pharmacological coping strategies like expressing feelings, exercise, and art therapy should be prioritized initially.

Question 5 of 5.

The nurse assesses that a hospitalized 20-year-old college student is anxious and not able to concentrate when given self-care instructions. Which intervention should the nurse implement to assist the client to deal with the stress of hospitalization?

A. Have one parent stay in the room when the client is anxious

B. Encourage using a cell phone or Internet to talk with friends

C. Contact psychiatry to discuss treatments for depression

D. Reinforce multiple times how best to perform self-care

Explanation: To enhance coping, the nurse should focus on the developmental needs of a young adult, which include interaction with peers. Using a cell phone or Internet to communicate with friends assists in dealing with hospitalization stress. Parental presence may be intrusive, the client shows no depression, and reinforcing self-care doesn't address emotional needs.