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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. BMI 32: A BMI of 30 or higher indicates obesity, which is a major risk factor for developing type 2 diabetes mellitus. Excess body fat, especially abdominal fat, contributes to insulin resistance, increasing the likelihood of diabetes.
B. Alcohol use: While excessive alcohol intake can affect overall health, moderate alcohol consumption is not a primary direct risk factor for type 2 diabetes. Other factors like obesity and sedentary lifestyle have a stronger association.
C. Age 35 years: Advancing age increases diabetes risk, but significant age-related risk typically rises after age 45. At 35 years old, age alone is not considered a major risk factor without additional contributing conditions.
D. Medical history of asthma: Asthma is a chronic respiratory condition but is not recognized as a risk factor for type 2 diabetes mellitus. The primary risk factors involve metabolic, genetic, and lifestyle components rather than respiratory history.
Correct Answer is C
Explanation
A. Serosanguinous drainage on dressing: Serosanguinous drainage, which is a mixture of clear and blood-tinged fluid, is a common and expected finding in the early postoperative period. It typically indicates normal healing unless the amount becomes excessive or the drainage changes character.
B. Hypoactive bowel sounds: Hypoactive bowel sounds are common within the first 24 to 48 hours following surgery, especially after general anesthesia or abdominal procedures. This finding is expected and does not immediately require provider notification unless accompanied by other concerning signs like severe abdominal distention.
C. Urinary output of 25 mL/hr: Urinary output should be at least 30 mL/hr to indicate adequate kidney perfusion and hydration. An output of 25 mL/hr suggests possible hypovolemia, renal impairment, or urinary retention, and it should be promptly reported to the provider for further evaluation.
D. Pain level of 2 on 0 to 10 scale: A pain score of 2 indicates mild pain, which is manageable and expected after surgery. This level of discomfort does not require urgent reporting to the provider as long as it remains controlled and does not interfere with recovery activities.
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