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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Documenting the pain is important but does not address the client’s immediate need for pain relief.
B. Waiting to re-evaluate in 1 hour delays intervention and does not prioritize the client’s current high pain level.
C. Asking the client what has helped relieve their pain in the past allows the nurse to assess effective interventions and tailor immediate pain management, making this the first action.
D. Obtaining a prescription may be necessary, but the nurse should first assess the client’s response to previous interventions and preferences before taking further steps.
Correct Answer is B
Explanation
Rationale:
A. A client whose TPN was discontinued and is requesting clear liquids can safely progress diet as prescribed but does not represent an immediate threat to life.
B. Delayed capillary refill after a cardiac catheterization indicates decreased perfusion, possibly from an arterial occlusion or compromised circulation at the insertion site. This is a priority because impaired circulation can lead to limb ischemia and loss if not addressed immediately.
C. Pain management for a postoperative client is important but not life-threatening and can be addressed after circulation is ensured.
D. An oxygen saturation of 90% in a client with COPD may be acceptable, as their baseline oxygen saturation is often lower than average, making this a lesser priority compared to impaired perfusion.
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