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.

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

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Correct Answer is A

Explanation

Choice A rationale

Applying petroleum jelly to the glans of the penis is an important step in the care of a newborn who has undergone a Gomco circumcision. This acts as a protective barrier to prevent the glans from sticking to the diaper, which can cause pain and disrupt the healing process. This is done with each diaper change for the first few days.

Choice B rationale

The yellow, sticky exudate that forms on the glans is a normal part of the healing process and is composed of fibrin and serum. Wiping it off can disrupt the healing tissue and increase the risk of bleeding and infection. The parent should be instructed to allow this exudate to fall off naturally.

Choice C rationale

Applying gentle pressure with a diaper is not an appropriate intervention. The area should be kept as free from pressure as possible to promote healing and reduce discomfort. Pressure could cause bleeding, pain, or damage to the delicate new tissue that is forming.

Choice D rationale

Alcohol is a harsh astringent that can cause significant pain and irritation to the sensitive, healing tissue of the glans. It can also dry out the skin, delaying the healing process. Only warm water should be used to clean the area during diaper changes. .

A. Insert a larger gauge IV catheter to prevent phlebitis. B. Choose the client's dominant arm for IV access whenever possible. C. Select a site proximal to previous venipuncture sites. D. Initiate IV access on the palmar side of the client's wrist.

Correct Answer is C

Explanation

Choice A rationale

While larger gauge catheters (e.g., 18-gauge) are used for rapid infusion, they also cause more trauma to the vein's intimal layer during insertion. This trauma can trigger a localized inflammatory response, increasing the risk of phlebitis, which is inflammation of the vein. Smaller gauge catheters (e.g., 22-24 gauge) cause less trauma and are preferred for routine fluid administration to prevent this complication.

Choice B rationale

The non-dominant arm is the preferred site for IV access whenever possible. Using the non-dominant arm allows the client to maintain more normal function and independence with daily activities, as they can still use their dominant hand without the restriction of the IV line. This also minimizes the risk of accidental dislodgement or trauma to the site.

Choice C rationale

Selecting a site proximal to previous venipuncture sites is the recommended practice. When a vein is punctured, it can cause localized inflammation and scar tissue formation distal to the site. Starting proximal allows for the use of a healthier segment of the vein, which improves the likelihood of successful insertion and reduces the risk of extravasation or phlebitis.

Choice D rationale

The palmar side of the client's wrist should be avoided for IV insertion. This area contains a high concentration of nerves and tendons, including the median nerve and radial artery. Inserting a catheter here increases the risk of nerve damage, which can lead to permanent numbness, tingling, or pain, and also increases the risk of arterial puncture. *.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching the parent of a newborn who underwent a circumcision using the Gomco method. Which of the following statements by the parent indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is inserting a short peripheral IV catheter for a client who requires IV fluids. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take first?

A nurse is reviewing the ECG tracing strip of a client who is receiving telemetry monitoring. The nurse should locate the S-T segment at which of the following locations on the electrocardiographic waveform.

The nurse should first address the client’s dropdown followed by the client’s dropdown.

A nurse is assessing a client who is postpartum and has developed endometritis. Which of the following findings should the nurse expect?

A nurse is providing discharge teaching to a client who has GERD. Which of the following information should the nurse include?

A nurse is preparing regular and NPH insulin in the same syringe for a client who has diabetes mellitus. Which of the following actions should the nurse take?

A school nurse is using the Weber's test to check a child's hearing acuity. Which of the following actions should the nurse take?

A nurse is caring for four children in an emergency department. Which of the following clients should the nurse assess first?