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 C
Explanation
Choice A rationale
This statement is dismissive of the client's concern and incorrectly implies that medication is a required part of rest and recovery. The client has the right to refuse medication, and this statement does not address their fears about being forced to take drugs. Providing false reassurance or being dismissive can damage the therapeutic nurse-client relationship and increase the client's anxiety.
Choice B rationale
This is an inappropriate response as it places the burden of explanation on the client and can be perceived as an accusatory question. Therapeutic communication requires the nurse to validate the client's feelings and provide accurate information, not to question their rationale.
The nurse should address the client's fear directly and reassure them about their rights.
Choice C rationale
This statement is correct because it upholds the client's rights. Under involuntary admission, a client retains the right to refuse psychotropic medication unless a court order has been obtained or there is an emergency situation where the client is a danger to themselves or others. The nurse's statement respects the client's autonomy and provides accurate information about their legal rights.
Choice D rationale
This statement is legally and ethically incorrect. Even with an involuntary admission, a client retains their fundamental rights, including the right to refuse treatment. Forcing a client to accept treatment against their will is a violation of their autonomy and can only be done in specific, legally defined circumstances, such as an emergency or through a court order. This response is coercive and non-therapeutic. *.
Correct Answer is B
Explanation
Choice A rationale
A tympanogram is a diagnostic test that measures the movement of the eardrum in response to changes in air pressure in the ear canal. It is used to assess the function of the middle ear and is not a part of the Weber's test. The Weber's test is a gross screening tool for hearing acuity that uses a vibrating tuning fork to compare bone conduction in both ears, not to evaluate middle ear function.
Choice B rationale
The Weber's test is a simple screening tool to detect unilateral hearing loss. The nurse places a vibrating tuning fork on the midline of the child's head, such as the forehead or the top of the head. The sound is transmitted through the skull bones to the inner ears. The child is asked where the sound is heard best—in the left ear, right ear, or equally in both. This assesses bone conduction.
Choice C rationale
The Weber's test evaluates whether the sound is heard equally in both ears or lateralizes to one ear, indicating a potential conductive or sensorineural hearing loss. It does not measure the duration of sound perception. Measuring the amount of time a client can hear the sound after the tuning fork is placed on the mastoid bone is part of the Rinne test, a different component of hearing assessment, which compares bone and air conduction.
Choice D rationale
Holding a vibrating tuning fork 1 to 2 cm from the ear canal is a procedure used for the Rinne test, not the Weber's test. The Rinne test compares air conduction to bone conduction. The vibrating tuning fork is placed first on the mastoid bone (bone conduction) and then near the ear canal (air conduction). This is used to distinguish between conductive and sensorineural hearing loss. *.
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