ATI LPN
PN Comprehensive Predictor 2020 Questions
Extract:
Nurses Notes
Day 1, 12:00:
Transferred to medical-surgical unit from emergency department (ED) for continued care following a closed reduction and immobilization of a fracture of the right arm. Accompanied by adult child.
Client in visibly soiled night clothes with multiple stains, including what appears to be dried blood. Hair, teeth, and fingernails unclean. Strong body odor noted. Bruising of various stages noted around upper arms, back, shoulders, and neck area.
Client is soft-spoken, speaks almost in a whisper, does not make eye contact with nurse.
Client looks at their child before answering the nurse's questions and, when asked how the injury occurred, mumbles, "I don't know. Ask them." Client's child states, "He gets confused sometimes. I can answer your questions."
Question 1 of 5
Nurses Notes Day 1, 12:00: Transferred to medical-surgical unit from emergency department (ED) for continued care following a closed reduction and immobilization of a fracture of the right arm. Accompanied by adult child. Client in visibly soiled night clothes with multiple stains, including what appears to be dried blood. Hair, teeth, and fingernails unclean. Strong body odor noted. Bruising of various stages noted around upper arms, back, shoulders, and neck area. Client is soft-spoken, speaks almost in a whisper, does not make eye contact with nurse. Client looks at their child before answering the nurse's questions and, when asked how the injury occurred, mumbles, 'I don't know. Ask them.' Client's child states, 'He gets confused sometimes. I can answer your questions.' The nurse is identifying tertiary prevention strategies to implement for this client. Select the three actions the nurse should take.
Correct Answer: C,E,F
Rationale: Reporting suspected abuse, asking about the fracture, and interviewing privately are tertiary prevention steps to address and mitigate harm. Insisting, informing, or confronting may escalate without evidence.
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