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 B
Explanation
The correct answer is Choice B.
Choice A rationale: Maintaining bed elevation at 20 degrees is not recommended. The recommended bed elevation for patients receiving enteral tube feedings is at least 30 to 45 degrees.This is to prevent aspiration of the feeding solution into the lungs.
Choice B rationale: Flushing the tubing with 30 mL of water every 4 hours is a recommended practice.This helps to maintain the patency of the feeding tube and prevent clogging.
Choice C rationale: Checking for gastric residual every 12 hours is not sufficient.For patients receiving continuous tube feedings, gastric residual volume (GRV) should be monitored every 4 hours.This helps to assess tolerance to the feeding and prevent complications such as aspiration.
Choice D rationale: Placing enough formula in the container to last 18 hours is not recommended.For an open system, the formula should be replaced every 4 hours to prevent bacterial growth.
Correct Answer is A
Explanation
Choice A rationale:
Dysphagia (difficulty swallowing) is a common complication of esophageal cancer and can lead to malnutrition and aspiration pneumonia. It is the priority finding because addressing the client's ability to swallow is essential for maintaining adequate nutrition and preventing complications.
Choice B rationale:
Xerostomia (dry mouth) is another common side effect of radiation therapy, but while uncomfortable, it does not pose an immediate risk to the client's health compared to dysphagia.
Choice C rationale:
Excoriation of the skin on the neck and chest is likely due to the radiation therapy and can be managed with appropriate skin care measures. Although important, it is not the priority compared to dysphagia.
Choice D rationale:
The client's self-reported pain level of 6 on a scale from 0 to 10 is concerning and requires attention, but addressing dysphagia takes precedence due to its potential impact on the client's nutritional status and overall well-being.
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