A nurse is assessing a client who has pericarditis. Which of the following findings is the priority?

 

A.

A. "Reporting the incident to Adult Protective Services" is crucial when there are signs of elder abuse or neglect. This action ensures that appropriate interventions are initiated to protect the client.

B. "Interviewing the client with his adult child present" may not allow the client to speak freely, especially if the adult child is the perpetrator or involved in the abuse. Confidentiality and safety are essential considerations.

C. "Telling the client he must answer every assessment question" can be intimidating and may not facilitate open communication, especially in situations involving abuse.

D. "Advising the client to consult a social worker" may be appropriate after reporting the incident to Adult Protective Services, but it is not the initial action to take when abuse is suspected. Reporting to authorities is the priority to ensure the client's safety.

A. A client who has an ileal conduit and mucus in the pouch - While mucus in the ileal conduit pouch should be monitored, it is not an urgent priority compared to assessing for potential complications such as bleeding in another client.

B. A client who has an arteriovenous fistula that vibrates when palpated - A vibrating arteriovenous fistula indicates normal functioning and does not require immediate assessment.

C. A client who had a transurethral resection of the prostate with red-tinged urine in the bag - Red-tinged urine may indicate bleeding, a potential complication after a transurethral resection of the prostate, requiring prompt assessment and intervention.

D. A client who has chronic kidney disease with cloudy dialysate outflow - While cloudy dialysate outflow may indicate infection or other complications in a client with chronic kidney disease on peritoneal dialysis, it is not as urgent as assessing for bleeding in the client with red- tinged urine.