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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. Contact precautions typically involve wearing gloves and a gown to prevent the spread of infectious agents through direct contact. Masks are not generally required for visitors unless the client is also on droplet or airborne precautions. Therefore, this statement reflects a misunderstanding of the specific requirements for contact precautions.
B.A client with compromised immunity should be placed in a positive-pressure airflow room, not a negative-pressure room. Positive-pressure rooms help prevent outside contaminants from entering the room, thereby protecting the immunocompromised client.
C. Clients on airborne precautions (e.g., for tuberculosis, varicella, or measles) should wear a mask if they need to leave their room to prevent the spread of airborne pathogens to others. This helps to contain infectious particles and protect others from exposure.
D. An N95 respirator mask is required for airborne precautions, not droplet precautions. For droplet precautions (e.g., for influenza, pertussis), a standard surgical mask is sufficient to protect against respiratory droplets.

A. Pouching a client's ostomy bag for a new colostomy B. Performing nasal hygiene for a client who has an NG tube C. Measuring oxygen saturation for a client who has dyspnea D. Inserting a rectal suppository for a client who is vomiting

Correct Answer is B

Explanation

A. Pouching a client's ostomy bag for a new colostomy requires specialized training and should typically be performed by a nurse.
B. Performing nasal hygiene for a client with an NG tube involves basic hygiene tasks that can be safely delegated to an assistive personnel after proper training and supervision.
C. Measuring oxygen saturation for a client who has dyspnea requires a basic skill that can be delegated to an assistive personnel.
D. Inserting a rectal suppository for a vomiting client involves a nursing task that should be performed by a nurse due to the client's condition and the nature of the task.

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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?

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