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 ["A","B","E","F","H","I"]
Explanation
Rationale:
A. Hydration status: Nausea, vomiting, and limited oral intake put the client at risk for dehydration, requiring monitoring and possible intervention.
B. Heart rate: Increased from 80/min at 1730 to 102/min at 2300, indicating possible systemic stress or dehydration.
E. Headache: Client reports a severe headache (7/10), which can indicate systemic worsening or complications.
F. Temperature: Rose to 39° C (102.2° F), showing worsening infection.
H. Emesis: Client vomited 230 mL, which can contribute to fluid and electrolyte imbalance.
I. Blood pressure: Increased from 118/72 mm Hg to 152/92 mm Hg, suggesting possible stress response, pain, or early complications.
Correct Answer is C
Explanation
Rationale:
A. The SBAR communication tool is used for structured communication among health care providers, not for measuring outcomes.
B. Flowcharts are used to map processes and identify where problems may occur, but they do not measure outcomes.
C. Clinical indicators are measurable items that reflect the quality of care provided (e.g., infection rates, fall rates, readmission rates). They are the appropriate tool for evaluating outcomes in quality improvement.
D. Cause-and-effect diagrams (Ishikawa or fishbone diagrams) are used to identify potential causes of a problem, not to measure outcomes.
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