A nurse is admitting an older adult client who is transferring from another facility.
The nurse notes pressure ulcers on the client's coccyx and abrasions around both wrists.
Which of the following actions should the nurse take to address suspicions of elder abuse?

Contact the family regarding the client's condition.

Notify risk management.

Inform the transferring agency of the client's condition.

Privately interview the client about the injuries.

Answer and Explanation

The Correct Answer is D

The correct answer is choice d. Privately interview the client about the injuries.

Choice A rationale:

Contacting the family regarding the client’s condition might not be appropriate if the family is suspected of being involved in the abuse. It could potentially put the client at further risk.

Choice B rationale:

Notifying risk management is important for documentation and internal review, but it does not directly address the immediate need to assess and ensure the client’s safety.

Choice C rationale:

Informing the transferring agency of the client’s condition is necessary for continuity of care, but it does not address the immediate need to investigate the cause of the injuries and ensure the client’s safety.

Choice D rationale:

Privately interviewing the client about the injuries allows the nurse to gather more information about the cause of the injuries in a safe and confidential manner. This step is crucial in assessing the situation and determining if further action, such as reporting to authorities, is needed. It ensures the client’s safety and helps in identifying any potential abuse.

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Correct Answer is A

Explanation

The correct answer is choiceA. Lift the penis so that it is perpendicular to the client’s body.

Choice A rationale:

Lifting the penis so that it is perpendicular to the client’s body straightens the urethra, making it easier to insert the catheter without causing trauma.

Choice B rationale:

While cleansing the tip of the penis in a circular motion is important for maintaining aseptic technique, it is not the specific action that facilitates the insertion of the catheter.

Choice C rationale:

Picking up the catheter 13 cm (5 in) from its tip is not a standard practice.The nurse should hold the catheter closer to the tip to maintain control and ensure accurate insertion.

Choice D rationale:

Inflating the catheter balloon before insertion can cause trauma to the urethra and is not recommended.The balloon should only be inflated once the catheter is correctly positioned in the bladder.

A. Include any adverse effects of the medications the client might develop. B. Compare new prescriptions with the list of medications the client reports. C. Exclude nutritional supplements from the list of medications the client reports. D. Encourage the client to make his own list after he returns to his home.

Correct Answer is B

Explanation

Choice A rationale:

Including any adverse effects of the medications the client might develop is important but does not cover the entire scope of medication reconciliation. It is essential to compare new prescriptions with the list of current medications to prevent drug interactions, duplications, or omissions.

Choice B rationale:

Comparing new prescriptions with the list of medications the client reports is the correct approach to medication reconciliation. This helps identify discrepancies, ensuring that the client's current medications are accurately documented and preventing medication errors.

Choice C rationale:

Excluding nutritional supplements from the list of medications the client reports is incorrect. Nutritional supplements, herbal remedies, and over-the-counter medications are essential components of the medication list. These items can interact with prescribed medications and affect the client's overall health.

Choice D rationale:

Encouraging the client to make his own list after he returns home is not recommended. Patients might not have complete knowledge of the medications they are taking, including dosages and frequencies. Relying solely on the patient-generated list can lead to inaccuracies and potential harm.

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A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the client's coccyx and abrasions around both wrists. Which of the following actions should the nurse take to address suspicions of elder abuse?

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A nurse is admitting an older adult client who is transferring from another facility.
The nurse notes pressure ulcers on the client's coccyx and abrasions around both wrists.
Which of the following actions should the nurse take to address suspicions of elder abuse?