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.
Treat and discharge the client.
File an incident report.
The Correct Answer is A
A. Asking the client's son to go to the waiting area allows the nurse to have a private conversation with the client, which is crucial in suspected cases of elder abuse to gather information without potential interference or intimidation.
B. Asking about injuries with the son present might hinder the client from disclosing information due to fear or pressure.
C. Treating and discharging the client without addressing the suspected elder abuse could potentially put the client in further danger.
D. Filing an incident report might be necessary but should follow an assessment and investigation of the situation.
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Related Questions
Correct Answer is B
Explanation
- A: This client requires initial teaching, which is typically the responsibility of a registered nurse due to the educational aspect and the need to assess the client's understanding.
- B: Administering an enema is a task that falls within the scope of practice for a licensed practical nurse and does not require the advanced assessment skills of a registered nurse.
- C: Developing an initial plan of care involves comprehensive assessment and critical thinking, which are responsibilities of a registered nurse.
- D: A client transferring from the CCU after a myocardial infarction would require close monitoring and assessment, which are beyond the scope of practice for a licensed practical nurse.
Correct Answer is B
Explanation
A. Withholding the opioid may lead to inadequate pain relief, which isn't the best approach, especially in a terminally ill patient experiencing severe pain.
B. Continuing the medication dosages that relieve pain is important for the client's comfort, even if it causes somnolence.
C. Contacting the provider to consider an NSAID might be an option, but immediate relief should not be compromised while awaiting a change in medication.
D. Withholding the benzodiazepine might be considered if the sedation is excessive, but prioritizing pain relief is crucial in end-of-life care unless there are severe adverse effects.
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