A home health nurse is conducting an admission assessment of an elderly patient who has their caregiver present.

Which observation should the nurse identify as a potential sign of elder abuse?

The patient is in a wheelchair with the wheels locked.

The patient reports receiving a full bath twice each week.

The caregiver insists on staying in the room.

The caregiver is the patient’s financial power of attorney.

Answer and Explanation

The Correct Answer is C

Choice A rationale

A patient being in a wheelchair with the wheels locked does not necessarily indicate elder abuse. It could simply mean that the patient has mobility issues and the wheelchair is a means of transportation for them. The wheels being locked could be a safety measure to prevent the wheelchair from moving unexpectedly.

Choice B rationale

The patient reporting receiving a full bath twice each week does not indicate elder abuse. In fact, it shows that the patient’s hygiene needs are being met regularly. Regular bathing is part of good personal hygiene and is important for overall health.

Choice C rationale

The caregiver insisting on staying in the room during the nurse’s assessment could be a potential sign of elder abuse. This could indicate that the caregiver is controlling or overbearing, and may be trying to monitor or control the patient’s interactions with others. It could also suggest that the caregiver is trying to hide something or prevent the patient from speaking freely.

Choice D rationale

The caregiver being the patient’s financial power of attorney does not necessarily indicate elder abuse. A financial power of attorney is a legal document that gives someone the authority to handle financial transactions on behalf of another person. It is often used when a person is unable to manage their own financial affairs due to illness or incapacity.

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Correct Answer is D

Explanation

Choice A rationale: Initiating a cardiac enzyme panel can help determine if the client has had a heart attack. However, this is not the immediate priority. The client’s symptoms suggest a possible cardiac event, which needs to be addressed first. An ECG can provide immediate information, while a cardiac enzyme panel takes longer to return results.

Choice B rationale: Starting intravenous fluid therapy may be necessary depending on the client’s hydration status and overall condition. However, it is not the immediate priority. The client’s symptoms suggest a possible cardiac event, which needs to be addressed first.

Choice C rationale: Providing pain relief medication may be necessary if the client is in pain. However, the client’s primary complaint is chest tightness and difficulty breathing, not pain. Therefore, addressing the potential cardiac issue is the priority.

Choice D rationale: The client’s symptoms of sudden shortness of breath, chest tightness, and anxiety, along with her history of hypertension and diabetes, are concerning for a possible cardiac event. An electrocardiogram (ECG) can provide immediate information about the heart’s electrical activity and help identify if the client is experiencing a heart attack or other cardiac event. This should be the first action taken to quickly identify the cause of the client’s symptoms and initiate appropriate treatment.

Choice E rationale: Performing a comprehensive physical assessment is an important part of nursing care. However, in this situation, the client’s symptoms indicate a need for immediate intervention to address her potential cardiac issue.

Choice F rationale: Monitoring the client’s blood glucose levels is important given her history of diabetes. However, this is not the immediate priority. The client’s symptoms suggest a possible cardiac event, which needs to be addressed first.

A. Walking briskly B. Riding a bicycle C. Performing isometric exercises D. Engaging in high-impact aerobics

Correct Answer is A

Explanation

Choice A rationale

Walking briskly is a weight-bearing exercise that is essential for maintaining bone mass, which can help to prevent osteoporosis. Regular weight-bearing exercise, such as a 20-30-minute aerobic exercise, 3 times a week, is recommended for older adults at risk for osteoporosis.

Choice B rationale

Riding a bicycle is a non-weight-bearing exercise. While it can contribute to overall fitness and health, it does not provide the same benefits for bone health as weight-bearing exercises like walking.

Choice C rationale

Performing isometric exercises can help to strengthen muscles, but these exercises do not have the same impact on bone health as weight-bearing exercises.

Choice D rationale

Engaging in high-impact aerobics can be beneficial for bone health, but it may not be suitable for an older adult at risk for osteoporosis due to the increased risk of injury.

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A home health nurse is conducting an admission assessment of an elderly patient who has their caregiver present. Which observation should the nurse identify as a potential sign of elder abuse?

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Correct Answer is D

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A home health nurse is conducting an admission assessment of an elderly patient who has their caregiver present.

Which observation should the nurse identify as a potential sign of elder abuse?