a nurse is collecting data from an older adult client during a routine physical examination which of the following client statements should the nurse
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1. A nurse is collecting data from an older adult client during a routine physical examination. Which of the following client statements should the nurse identify as a possible indication of maltreatment?

Correct answer: A

Rationale: The correct answer is A. Taking away a wallet to control spending is a form of financial maltreatment, which is a common form of abuse among older adults. Choices B, C, and D do not indicate maltreatment; rather, they show examples of care and concern from the son. Cooking meals, preventing the older adult from driving alone, and engaging in daily exercise are positive behaviors.

2. A nurse is observing an assistive personnel (AP) caring for a client. For which of the following actions by the AP should the nurse intervene?

Correct answer: B

Rationale: The correct answer is B because reporting client information in the hallway violates privacy regulations, compromising patient confidentiality. Providing care in the hallway (choice A) may not be ideal but is not a direct violation. Helping another client use the restroom (choice C) shows the AP's willingness to assist but is not a concern unless it compromises the current client's safety. Feeding the client too quickly (choice D) is a potential concern for aspiration but may not require immediate intervention as addressing hydration and swallowing strategies can help prevent complications.

3. What is the most appropriate safety measure for a client using home oxygen?

Correct answer: B

Rationale: The correct answer is to ensure oxygen tanks are kept upright at all times. This is important to prevent the tanks from falling over, which can lead to injuries or tank damage. Choice A is incorrect because oxygen tanks should not be stored in a closet when not in use, as this can lead to poor ventilation and potential hazards. Choice C is incorrect because smoking near oxygen tanks poses a significant fire risk. Choice D is incorrect because while it is important to keep oxygen equipment away from heat sources, ensuring the tanks are kept upright is a more critical safety measure.

4. How should a healthcare provider assess and manage a patient with anemia?

Correct answer: A

Rationale: Corrected Question: To assess and manage a patient with anemia, monitoring hemoglobin levels and providing iron supplements are crucial. Anemia is commonly caused by iron deficiency, making iron supplementation a cornerstone of treatment. B12 injections (Choice B) are more relevant for treating megaloblastic anemia, not the typical iron-deficiency anemia. Monitoring for signs of infection and administering folic acid (Choice C) are important in specific types of anemia like megaloblastic anemia, but not the first-line approach for anemia management. Administering oxygen therapy (Choice D) is not the primary intervention for anemia unless severe hypoxemia is present, which is not typically seen in anemia.

5. After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a five-year-old child is admitted to the emergency room. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessments, if observed by the nurse three hours after admission, should be reported to the physician?

Correct answer: B

Rationale: Clear fluid draining from the ear can indicate cerebrospinal fluid leakage, which is a serious concern after a head injury. This leakage can signify a skull fracture or damage to the meninges, potentially leading to infection. Therefore, it should be reported immediately for further evaluation and management. Choices A, C, and D are typical findings after head trauma and are not as urgent as the presence of clear fluid draining from the ear.

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