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
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. .
Correct Answer is A
Explanation
Choice A rationale
Measuring the client's legs with a tape measure is the correct action to ensure proper sizing of the antiembolic stockings. Correct sizing is critical for effective venous compression and to prevent complications such as skin irritation, tissue damage, or impaired circulation. Stockings that are too tight can act as a tourniquet, while those that are too loose will not provide the necessary graduated compression to facilitate venous return and prevent blood stasis, which is the underlying cause of deep-vein thrombosis. This precise measurement ensures the stockings fit snugly and provide optimal therapeutic benefit.
Choice B rationale
Removing the stockings every 24 hours is an insufficient interval for skin integrity checks and to allow for proper cleaning and assessment. The standard practice involves removing antiembolic stockings at least twice daily for a short period. This allows the nurse to inspect the client's skin for any signs of pressure, irritation, or breakdown, and to perform hygiene. Prolonged, continuous wear without breaks can compromise skin integrity and increase the risk of developing pressure injuries, especially in a client who is less mobile due to their condition.
Choice C rationale
Folding the stockings at the top is a harmful and dangerous practice. Folding creates a constrictive band around the client's leg, which acts as a tourniquet. This constriction impedes venous and lymphatic return, leading to increased risk of blood stasis, edema, and tissue damage. The pressure from the folded band can severely compromise circulation and potentially worsen the client's underlying deep-vein thrombosis. The stockings should be smooth and wrinkle-free to provide uniform graduated compression.
Choice D rationale
Massaging the legs of a client with deep-vein thrombosis (DVT) is contraindicated and can be extremely dangerous. Massaging can dislodge the thrombus (blood clot) from the venous wall. If the clot becomes dislodged, it can travel through the bloodstream, leading to a pulmonary embolism (PE), a life-threatening condition where the clot obstructs a pulmonary artery in the lungs. Therefore, any form of massage or direct pressure on the affected limb is strictly avoided to prevent this potentially fatal complication. *.
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