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 B
Explanation
Choice A rationale
Tomato soup is highly acidic due to its tomato base, which can relax the lower esophageal sphincter (LES) and increase stomach acid production. This can lead to the reflux of gastric contents into the esophagus, exacerbating the symptoms of GERD. The client should avoid highly acidic foods to manage their condition effectively.
Choice B rationale
White fish is a lean protein that is generally low in fat. High-fat foods can delay stomach emptying and decrease the pressure of the lower esophageal sphincter, increasing the risk of acid reflux. Lean proteins like white fish are less likely to trigger symptoms and are therefore a suitable dietary choice for a client with GERD.
Choice C rationale
Hot cocoa contains both caffeine and fat, which are known to exacerbate GERD symptoms. Caffeine can relax the lower esophageal sphincter, allowing stomach acid to reflux. Additionally, the fat content can delay gastric emptying, increasing pressure on the LES and worsening acid reflux symptoms.
Choice D rationale
Decaffeinated coffee can still trigger GERD symptoms. Coffee, even without caffeine, is acidic and can stimulate the production of stomach acid. The oils and compounds in coffee can also relax the lower esophageal sphincter, increasing the likelihood of acid reflux and causing irritation to the esophageal lining.
Correct Answer is B
Explanation
Choice A rationale
Increasing the rate of formula delivery would worsen hyperosmolar dehydration. A faster rate delivers more solute-rich formula to the gastrointestinal tract in a shorter time, pulling more free water from the body's vascular space into the gut lumen via osmosis. This fluid shift further depletes the body's free water, intensifying the dehydration and increasing serum osmolality.
Choice B rationale
Hyperosmolar dehydration occurs when the body's free water is drawn into the gastrointestinal tract due to a high solute concentration in the enteral formula. By adding free water to the formula, the nurse dilutes the solution, lowering its osmolarity. This action helps to balance the osmotic gradient, reducing the fluid shift and preventing further dehydration.
Choice C rationale
Switching to a lactose-free formula is indicated for clients with lactose intolerance, which causes symptoms like diarrhea and bloating, but it does not directly address hyperosmolar dehydration. Hyperosmolar dehydration is related to the overall solute load and concentration of the formula, not specifically the presence or absence of lactose.
Choice D rationale
Repositioning the NG tube is an action to ensure proper placement and prevent complications like aspiration, but it does not resolve hyperosmolar dehydration. This type of dehydration is a systemic problem related to fluid and electrolyte balance, not a local issue with the tube's position within the gastrointestinal tract. *.
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