A nurse is caring for an 84-year-old female client in her home to establish home health care and perform an initial assessment.

Exhibits

Which intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.

Choice A rationale

The nurse’s signature on the surgical consent form does not verify the client’s understanding of the procedure. This responsibility lies with the physician or surgeon, who must ensure that the client is fully informed about the nature, risks, benefits, and alternatives of the procedure. The nurse’s role is to witness the client’s signature, confirming that the client has signed the form without coercion and is competent to do so.

Choice B rationale

The client’s competence to sign the consent form is a crucial aspect that the nurse witnesses. By signing as a witness, the nurse attests that the client is mentally sound and capable of making informed decisions about their medical care. This includes verifying that the client is not under the influence of substances that could impair judgment and that they understand the nature of the consent they are giving.

Choice C rationale

The client voluntarily granting permission for the procedure is another key element of the nurse’s witnessing role. The nurse’s signature confirms that the client has signed the consent form of their own free will, without any undue pressure or coercion. This ensures the validity of the consent and protects the client’s rights and autonomy in making healthcare decisions.

Choice D rationale

The explanation of the procedure, its necessity, and potential outcomes are the responsibility of the surgeon or physician. The nurse does not provide this detailed explanation but ensures that the client has had the opportunity to receive this information from the appropriate healthcare provider. The nurse’s signature does not verify that the surgeon has explained the procedure; it simply confirms the witnessing of the client’s signature.

Choice E rationale

Understanding the risks and benefits of the procedure is part of the informed consent process, which the physician or surgeon must explain to the client. The nurse’s role is to witness the client’s signature, ensuring that the client has had the opportunity to receive this information. The nurse’s signature does not confirm the client’s understanding of these details but indicates that the consent was signed voluntarily and competently.

TRALI is a life-threatening condition associated with blood transfusion. The client’s symptoms, including trauma and low hemoglobin, indicate the need for transfusion. TRALI can cause acute respiratory distress shortly after transfusion. Early intervention can improve outcomes. Recognizing the signs of TRALI is essential in such scenarios.

Rationale for actions

Administer oxygen: Oxygen supplementation can help manage hypoxemia associated with TRALI. It ensures adequate oxygenation during respiratory distress. Monitor for respiratory distress: Continuous assessment helps detect worsening symptoms. Early detection can prompt timely intervention. Rationale for parameters: Oxygen saturation: Monitoring SpO2 provides real-time information on the patient’s oxygenation status. It helps determine the effectiveness of oxygen therapy. Heart rate: Tachycardia can indicate worsening respiratory distress or hypoxemia. Monitoring heart rate is crucial for early detection of complications.

Rationale for incorrect conditions

Transfusion-associated circulatory overload (TACO): TACO involves fluid overload, leading to cardiac symptoms. However, this client’s presentation suggests acute lung injury, not fluid overload. Incorrect conditions (others): Abandonment: Not applicable as the client was brought to the hospital and received care. Physical abuse: No evidence of physical abuse in this case. Self-neglect: The client is a child, and the injury was accidental, not due to neglect. The parents brought him to the hospital promptly.