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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Maintaining eye contact with the newborn during feedings is a general caregiving practice and is not specific to managing neonatal abstinence syndrome. While eye contact and bonding are important for newborns, it does not address the symptoms of neonatal abstinence syndrome.
Choice B rationale:
Swaddling the newborn with his legs extended is not a specific action for managing neonatal abstinence syndrome. However, swaddling can provide comfort to some infants, but the positioning of the legs is not directly related to managing symptoms of withdrawal.
Choice C rationale:
Administering naloxone to the newborn is not a standard practice for managing neonatal abstinence syndrome. Naloxone is an opioid antagonist used to reverse opioid overdose in adults and is not typically used in newborns unless there are specific indications, which are rare.
Correct Answer is A
Explanation
The correct answer is A. Uses a firm-bristled toothbrush increases the client's risk for injury because it can cause bleeding gums and oral mucosal damage in clients with pernicious anemia, who have reduced platelet count and impaired clotting. The other findings do not increase the risk for injury and may be beneficial for clients with pernicious anemia. Increased intake of green, leafy vegetables provides folic acid, which is essential for red blood cell production. Drinks 2,500 mL of fluid per day prevents dehydration and maintains blood volume. Wears a face mask around others reduces exposure to infections, which can be serious in clients with pernicious anemia, who have impaired immunity due to low white blood cell count.
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