A client's adult child left the facility to go home and get the client's prescribed medications.
The client is visibly more relaxed and now speaking more openly to staff with improved eye contact.
The client reports they have lived with their adult child for the past several months due to their inability to care for themselves without assistance.
The client states their adult child "gets frustrated with me, but I understand why.
I move so slow and need help with everything.”. The client states they give their retirement income to their adult child to pay for their prescribed medication and household expenses, but they have no access to the bank account.
The client states their adult child makes "a few meals a week" and that there is little food in the house.
What should be the nurse's priority action based on this information?
Report suspected elder abuse to the appropriate authorities.
Ask the client's adult child about the client's financial situation.
Educate the client's adult child about the importance of nutrition.
Encourage the client to discuss their frustrations with their adult child.
The Correct Answer is A
Choice A rationale
Based on the client's statements, there is strong evidence of neglect and potential exploitation. Neglect is indicated by the inadequate food supply and minimal meal preparation. Financial exploitation is suggested by the client's lack of access to their retirement income, despite it being used for their care. This situation poses a serious risk to the client's well-being, triggering the nurse's ethical and legal duty to report suspected elder abuse to the appropriate authorities.
Choice B rationale
While gathering more information is often a good practice, directly questioning the adult child about financial matters could escalate the situation and potentially put the client at further risk. The primary responsibility of the nurse in this scenario is to ensure the client's safety, and the existing information is sufficient to warrant a report. The client has already provided a detailed account of the financial arrangement and their lack of access to funds, which is a key indicator of exploitation.
Choice C rationale
Educating the adult child about nutrition, while potentially helpful in some circumstances, does not address the immediate and serious issues of neglect and financial exploitation. The client's safety is the priority. Focusing solely on education ignores the broader pattern of abuse and the client's vulnerability, which requires a more direct and protective intervention.
Choice D rationale
Encouraging the client to speak with their adult child may place them in a more vulnerable position and could increase the risk of retaliation or further neglect. The client has already expressed an understanding of their adult child's frustration, and this approach fails to address the power imbalance and exploitative nature of the relationship. It is not an appropriate or safe intervention in a situation of suspected abuse. *.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Chills are a systemic manifestation of an infectious process and are commonly associated with endometritis. Endometritis is an infection of the uterine lining, which can cause a systemic inflammatory response. This response often includes fever and chills, as the body's immune system fights the invading pathogens, causing a thermoregulatory cascade. A temperature of 100.4°F (38°C) or higher is typical.
Choice B rationale
Back pain can occur with various postpartum conditions, but it is not a primary or specific finding for endometritis. While uterine cramping and pelvic pain are characteristic due to the uterine inflammation, back pain is not as specific. More classic signs are fever, lower abdominal pain, uterine tenderness, and foul-smelling lochia due to the presence of bacteria.
Choice C rationale
Tachycardia, not bradycardia, is an expected finding in a client with endometritis. Tachycardia is a physiological response to fever, infection, and the systemic inflammatory process. The heart rate increases to compensate for increased metabolic demand and to circulate immune cells more efficiently. Bradycardia would be an unusual and unexpected finding.
Choice D rationale
Agitation is not a primary or typical finding of endometritis. Endometritis is a physical infection of the uterine lining. While discomfort and fever may cause irritability, agitation is not a specific expected symptom. This finding is more associated with neurological or psychiatric conditions, or severe complications like septic shock, which is a more advanced state. *.
Correct Answer is B
Explanation
Choice A rationale
Administering a vasoconstrictor is a potential intervention for shock but it is not the first action. The client's hypotension and tachycardia are indicative of hypovolemic shock due to profuse vomiting, leading to fluid loss. The body's initial compensatory mechanism involves vasoconstriction to maintain blood pressure, so further constriction without addressing the volume deficit can worsen tissue perfusion.
Choice B rationale
The client is exhibiting signs of hypovolemic shock, including a low blood pressure of 86/58 mmHg, a high pulse of 114/min, and a high respiratory rate of 27/min. These are physiological compensations for reduced circulating blood volume. Increasing the intravenous infusion rate directly addresses the primary problem by rapidly replacing lost fluid volume, thereby increasing preload, stroke volume, cardiac output, and ultimately, blood pressure.
Choice C rationale
Elevating the client's feet can temporarily increase venous return to the heart and improve blood pressure. However, this is a passive measure that does not address the underlying fluid deficit causing the hypovolemic shock. It is a helpful adjunctive action but is not the definitive first-line intervention required to correct the circulatory collapse in this scenario.
Choice D rationale
Initiating oxygen therapy is a supportive measure for shock because it helps improve tissue oxygenation, which is compromised due to poor perfusion. While beneficial, it does not correct the root cause of the shock, which is the lack of circulating fluid volume. The most immediate and life-saving intervention is to restore fluid volume to improve cardiac output and blood pressure
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