A nurse is caring for a client who is in the latent phase of labor and reports severe back pain. The vaginal examination reveals that the cervix is dilated 2 cm, 25% effaced, and -2 station.
Which of the following interventions should the nurse implement?

Condition: Elder maltreatment 2 actions: Initiate a referral to adult protective services; Administer prescribed pain medication 2 parameters: Frequency and severity of bruises; Nutritional intake and weight

Rationale for correct condition The client’s physical signs (multiple bruises in various stages, unclean appearance), social indicators (dependency, financial control, food insecurity), and behavioral changes in the presence of the caregiver strongly suggest elder abuse. Elder maltreatment includes physical, emotional, financial, and neglectful harm. An 82-year-old with a BMI of 18.3 shows undernutrition. His improved demeanor away from the child reflects psychological coercion. Bruises in different stages may indicate repeated trauma over time.

Rationale for correct actions Referral to adult protective services ensures legal and social intervention and facilitates multidisciplinary evaluation for safety. Reporting is mandated and protects the client from further harm. Administering pain medication addresses acute injury (fracture of right radius) and helps restore comfort. Effective pain management is crucial for mobility and assessment of additional injuries.

Rationale for correct parameters Monitoring bruising patterns helps identify ongoing abuse and quantify recovery or new trauma. Repeated injuries in various healing stages are hallmark signs. Nutritional intake and weight reflect neglect; insufficient food intake leads to weight loss and reduced immune function. Tracking BMI and calorie intake can guide long-term recovery and support.

Rationale for incorrect conditions Osteoporosis-related fracture would more likely occur with minimal trauma and does not explain social neglect or emotional signs. Accidental fall may be plausible but lacks explanation for systemic neglect and coercion. Peripheral neuropathy doesn’t explain acute arm pain or psychosocial signs of neglect.

Rationale for incorrect actions Encouraging activity is inappropriate during acute fracture recovery and potential abuse. Bone density scans assess fragility but don’t address safety risks. Nutritional supplements may help but don’t resolve underlying maltreatment or acute injury.

Rationale for incorrect parameters Bone density is not immediately relevant and doesn't reflect maltreatment. Blood pressure fluctuations are not present and don’t indicate abuse. Grip strength cannot be assessed accurately with an arm fracture and isn't useful for abuse evaluation.

Take-home points • Elder maltreatment includes physical harm, neglect, emotional abuse, and financial exploitation • Victims may show improved responsiveness when abuser is absent • Multidisciplinary intervention via adult protective services is critical • Differentiation from accidental injury ensures proper protection and care

Choice A rationale

Cranberry juice has a low pH, creating an acidic environment in the gastrointestinal tract which can help to neutralize bacteria and reduce malodorous compounds like indole and skatole, thereby decreasing odor. This action is beneficial, so avoiding it is not the correct advice for odor control.

Choice B rationale

Breath mints or commercial deodorizers contain ingredients like peppermint or chlorophyll that chemically neutralize odor-causing volatile sulfur compounds produced during digestion. Placing a breath mint inside the ostomy pouch releases these agents, effectively masking and reducing the unpleasant smell from gas and stool.

Choice C rationale

Eggs are a rich source of sulfur-containing amino acids, such as cysteine and methionine. When these are digested by intestinal bacteria, they produce hydrogen sulfide gas, which is the primary contributor to a strong, unpleasant odor and increased flatus. Consuming eggs would exacerbate the problem.

Choice D rationale

Sugar-free gum often contains sugar alcohols like sorbitol or xylitol. These are poorly absorbed in the small intestine and are fermented by colonic bacteria, leading to the production of gas. This can increase flatus and may contribute to bloating and discomfort for the client.