A client who was a victim of a rape and was confirmed HIV positive six months ago arrives at the clinic for an appointment.

The client is thin, with a saddened affect and talks about frequently crying and feeling hopeless.

The client describes not wanting to see anyone or go out of the house.

Which action should the nurse take?

Choice A rationale

Asking the client to describe the pain is the most effective way to assess the quality of pain. This approach allows the client to provide specific details about their pain experience, including the type, intensity, and characteristics, which are essential for accurate pain management.

Choice B rationale

Identifying effective pain relief measures is important but does not directly assess the quality of pain. This step is more focused on treatment rather than the initial assessment of pain quality.

Choice C rationale

Observing body language and movement can provide additional information about the pain but is not as reliable as directly asking the client. Nonverbal cues should supplement, not replace, the client's verbal report.

Choice D rationale

Providing a numeric pain scale helps quantify the intensity of pain but does not assess the quality. Quality assessment requires a descriptive approach to understand the nature of the pain fully.

Choice A rationale

Short-term memory loss is not typically associated with elder mistreatment. It may result from normal aging, neurological conditions like Alzheimer's disease, or other medical issues affecting cognitive function. It does not directly indicate mistreatment.

Choice B rationale

Malnutrition in the elderly can be a sign of neglect or mistreatment, where the individual may not receive adequate nutrition due to inadequate caregiving or intentional withholding of food. It can lead to severe health complications and indicates a lack of proper care.

Choice C rationale

Bilateral leg edema can result from various medical conditions, such as heart failure, chronic venous insufficiency, or renal disease. It is not a specific indicator of elder mistreatment and requires a thorough medical evaluation to determine the underlying cause.

Choice D rationale

Diminished breath sounds are typically related to respiratory conditions, such as pneumonia, chronic obstructive pulmonary disease (COPD), or pleural effusion. While they require medical attention, they do not directly indicate elder mistreatment.

Choice E rationale

Dark room lighting can suggest poor living conditions and inadequate care, potentially indicating neglect or mistreatment. Proper lighting is essential for the safety and well-being of elderly individuals, and its absence may reflect a lack of proper care and attention.

Choice F rationale

Poor hygiene is a common sign of neglect in elder mistreatment cases. It indicates that the individual may not receive assistance with personal care, leading to physical and emotional distress. Neglecting hygiene needs can result in infections and other health issues.

Choice G rationale

Pressure injuries, or bedsores, are often a result of prolonged immobility and inadequate repositioning, which can occur in cases of elder mistreatment or neglect. These injuries can lead to severe complications and are indicative of a lack of proper care and attention to the individual's needs.