A nurse is caring for a group of older adult clients who receive home care.
Which of the following clients should the nurse interview about the possibility of caregiver abuse or neglect?
A client who has a bruise on their shin.
A client who is 9 kg (20 lb) over their recommended weight.
A client whose caregiver pays the client's bills.
A client who is wearing soiled clothing.
The Correct Answer is D
Choice A rationale
While a bruise on the shin could indicate abuse, it could also result from an accidental bump or fall, which are common in older adults due to factors like impaired balance or decreased bone density. A single bruise alone is not definitive evidence of caregiver abuse or neglect and requires further assessment to determine the cause.
Choice B rationale
Being 9 kg (20 lb) over the recommended weight is indicative of potential overeating or a sedentary lifestyle, both of which are health concerns but not direct indicators of caregiver abuse or neglect. Weight management is related to dietary habits and physical activity levels, not necessarily the actions of a caregiver.
Choice C rationale
A caregiver paying a client's bills is not necessarily indicative of abuse or neglect. It could be a sign of assistance and support, especially if the client has difficulty managing their finances. Financial arrangements between a client and caregiver need to be assessed within the context of their relationship and the client's capacity.
Choice D rationale
Wearing soiled clothing suggests a lack of proper hygiene and care, which could be a sign of neglect by the caregiver. Inadequate attention to basic needs like cleanliness can lead to skin breakdown, infections, and a decline in the client's overall health and well-being. This warrants further investigation into the care provided.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale: Pupils
Dilated pupils are a common sign of stimulant intoxication, particularly with substances like methamphetamine. Given that the client recently injected an unknown substance, pupil dilation could indicate acute intoxication and require urgent evaluation to prevent potential overdose or complications.
Choice B rationale: Heart rate
A heart rate of 121–124/min is significantly elevated, suggesting tachycardia, which can be related to stimulant use (such as methamphetamine) or withdrawal effects. High heart rates, especially in the context of withdrawal, can increase the risk of arrhythmias or cardiac complications, requiring close monitoring and intervention.
Choice C rationale: Orientation
The client was oriented only to person upon admission, which suggests altered mental status. Substance intoxication or withdrawal can impair cognitive function, decision-making, and awareness, increasing the risk for agitation, confusion, or more severe withdrawal symptoms such as hallucinations or seizures.
Choice D rationale: Respiratory rate
A respiratory rate of 20/min falls within the normal range (typically 12–20 breaths per minute) and does not indicate immediate distress requiring escalation of care.
Choice E rationale: Medical history
While knowing the client’s medical history is important for long-term care planning, it does not require immediate reporting unless the client has a history of conditions that could complicate withdrawal.
Choice F rationale: Oxygen saturation
An oxygen saturation of 98% on room air is within normal limits, meaning oxygenation is adequate. There is no immediate concern requiring intervention based on this finding.
Correct Answer is D
Explanation
Choice A rationale
Restraint prescriptions for adults typically need to be renewed every 24 hours, according to most healthcare facility policies and regulatory guidelines, not every 48 hours. This frequent review ensures ongoing assessment of the client's need for restraints.
Choice B rationale
Attaching restraints to the side rail of the client's bed is dangerous because the side rail can move independently of the bed frame. This can cause injury to the client if they try to move or reposition themselves, potentially leading to strangulation or other harm. Restraints should be secured to a stable part of the bed frame.
Choice C rationale
Maintaining 2 fingerbreadths between the restraint and the client's skin is the standard to ensure proper circulation and prevent skin breakdown. One fingerbreadth would be too tight and could compromise blood flow and nerve function.
Choice D rationale
Using a quick-release tie is essential for safety when applying restraints. This allows for rapid removal of the restraints in case of an emergency, such as compromised circulation or the need for immediate medical intervention.
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