A nurse is assisting in the care of an older adult. The client appears to be malnourished and bruising is noted on their arms and legs. The nurse should identify which of the following as the legal responsibility of the nurse?

Notifying the caregiver of the findings.

Including findings during hand-off report.

Documenting suspicions in the client's medical record

Reporting findings to social services.

Answer and Explanation

The Correct Answer is D

A. Notifying the caregiver of the findings: If the caregiver is potentially involved in abuse or neglect, informing them directly could put the client at further risk. The nurse must follow appropriate reporting channels rather than confront the caregiver.

B. Including findings during hand-off report: While communication during hand-off is important for continuity of care, it does not fulfill the nurse’s legal obligation to formally report suspected abuse or neglect to the appropriate authorities.

C. Documenting suspicions in the client's medical record: Accurate and objective documentation of findings is important, but simply recording observations in the medical record does not meet the legal responsibility to report suspected abuse.

D. Reporting findings to social services: Nurses are mandated reporters and must legally report suspected abuse or neglect to the appropriate protective services. Reporting ensures that an investigation can occur to protect the client from further harm.

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Correct Answer is C

Explanation

A. "I have nosebleeds once per week.": Occasional nosebleeds are relatively common during pregnancy due to hormonal changes causing increased vascularity and congestion of the nasal passages. While the frequency should be noted, it's generally not a priority to report unless they are severe, frequent, or difficult to control.

B. "My heart feels like it skips a beat.": Palpitations can occur during pregnancy because of increased blood volume and changes in cardiovascular function. Occasional palpitations are typically benign but should be further evaluated if they become persistent or are associated with other symptoms like chest pain.

C. "I am experiencing persistent headaches.": Persistent headaches during pregnancy, especially after 20 weeks gestation, can be a warning sign of preeclampsia, a serious hypertensive disorder. Reporting this symptom immediately is critical to assess for elevated blood pressure, proteinuria, and other complications.

D. "The palms of my hands are red and blotchy.": Red, blotchy palms, known as palmar erythema, are a common and harmless finding during pregnancy due to increased estrogen levels. It does not usually indicate any serious condition and does not require urgent reporting.

A. "I have switched from tobacco cigarettes to electronic cigarettes.” B. "Sometimes I am exposed to toxic chemicals at my workplace, but not any that have harmed me." C. "Two of my grandparents had diabetes, so I try to eat a healthy diet." D. "My job and home life are both very stressful, but I haven't been able to do anything about that.”

Correct Answer is C

Explanation

A. "I have switched from tobacco cigarettes to electronic cigarettes.": Although electronic cigarettes may reduce exposure to certain harmful chemicals found in tobacco smoke, they still pose significant health risks. This change does not reflect truly limiting risky behavior but rather substituting one form of risk for another.

B. "Sometimes I am exposed to toxic chemicals at my workplace, but not any that have harmed me.": Exposure to toxic chemicals, even without immediate harm, still represents ongoing risk. A proactive approach would involve using protective equipment or seeking safer work conditions.

C. "Two of my grandparents had diabetes, so I try to eat a healthy diet.": Actively modifying diet in response to a family health history shows a positive, preventative approach and reflects conscious efforts to limit risk-taking behaviors and promote long-term health.

D. "My job and home life are both very stressful, but I haven't been able to do anything about that.": Chronic unmanaged stress is a health risk, and acknowledging stress without taking steps to manage it indicates that the client is not effectively limiting risk behaviors.

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A nurse is assisting in the care of an older adult. The client appears to be malnourished and bruising is noted on their arms and legs. The nurse should identify which of the following as the legal responsibility of the nurse?

Nursing Test Bank

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