A nurse is assessing an older adult client who was brought to the emergency department by his adult son, who reports that the client fell at home. The nurse suspects elder abuse. Which of the following actions should the nurse take?
Ask the client's son to go to the waiting area.
Ask the client about his injuries with the son present.
File an incident report.
Treat and discharge the client.
The Correct Answer is A
Rationale:
A. Asking the son to leave allows the nurse to interview and assess the client privately. This ensures the client can speak freely about possible abuse without fear of intimidation.
B. Asking about injuries in the presence of the possible abuser may prevent the client from disclosing abuse and could place the client at further risk.
C. An incident report is for internal facility events (e.g., falls, medication errors), not for suspected abuse. Abuse must be reported to the appropriate authorities, not just documented internally.
D. Discharging the client without investigation puts the client at continued risk of harm and fails to meet the nurse’s legal obligation to protect vulnerable populations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. A scalp laceration with heavy bleeding is urgent, but bleeding can often be controlled quickly; not immediately life-threatening once managed.
B. Chest pain with diaphoresis suggests myocardial infarction (MI) or another life-threatening cardiac condition → emergent priority because it requires immediate intervention to preserve life.
C. An open humerus fracture is urgent, but not typically immediately life-threatening.
D. Severe itching is nonurgent, not life-threatening at all.
Correct Answer is A
Explanation
Rationale:
A. A client with emphysema and an oxygen saturation of 92% is stable and within an expected range for this condition. This client’s care can be appropriately managed by an LPN.
B. Admission assessments must be completed by an RN, not an LPN.
C. Administration of blood products (RBCs) requires an RN due to the need for close monitoring and rapid intervention for transfusion reactions.
D. Initiating oral nutrition after a stroke involves swallowing assessment and risk for aspiration, which must be performed by an RN.
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