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.

Answer and Explanation

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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Correct Answer is ["A","C"]

Explanation

Rationale:
A. Client 3: The client is 4 days post–total hip replacement, ambulating well with assistance, and stable. This client is appropriate for discharge to free up beds.
B. Client 4: The client has COPD with a high fever and thick blood-tinged sputum, indicating acute illness that requires continued hospitalization.
C. Client 2: The client is preoperative for bariatric surgery, which can potentially be postponed or discharged preoperatively if stable, making them suitable for discharge in a mass casualty scenario.
D. Client 1: The client has ongoing chest pain with recent nitroglycerin use and cardiac monitoring, requiring continued inpatient care.
E. Client 5: The client is hypotensive and tachycardic due to dehydration, requiring ongoing IV fluids and monitoring, so discharge is unsafe.

A. A client who has emphysema and has an oxygen saturation level of 92% B. A client who has dehydration and is being admitted from the emergency department C. A client who is scheduled to receive 2 units of RBCs following a hip replacement D. A client who is scheduled to start oral nutrition 2 days after a cerebrovascular accident

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse on a medical-surgical unit is reviewing the electronic medical record on a group of clients during a mass casualty event. Exhibits Select the 2 clients that the nurse should recommend for discharge to make room for clients injured in the disaster.

Correct Answer is ["A","C"]

Explanation

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Correct Answer is A

Explanation

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