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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.

Develop a safety plan.

Perform a thorough physical assessment.

Report findings to Adult Protective Services.

Confront the abuser about concerning actions.

Take photographs to document the abuse or neglect.

Complete a comprehensive history.

Throw away soiled clothing.

Query the client in front of the suspected abuser.

Answer and Explanation

Correct Answer : A,B,C,E,F

Choice A rationale: Developing a safety plan is essential to ensure the client's immediate and long-term safety. This involves planning for safe living arrangements and other protective measures.

Choice B rationale: Performing a thorough physical assessment helps document the extent of injuries or neglect and provides critical information for further actions and interventions.

Choice C rationale: Reporting findings to Adult Protective Services is a necessary step to ensure that the client receives the appropriate protection and support from authorities.

Choice E rationale: Taking photographs to document the abuse or neglect provides visual evidence that can be used in investigations and legal actions to protect the client.

Choice F rationale: Completing a comprehensive history helps understand the full context of the client's situation, including past medical history, social support, and potential risk factors for mistreatment.

Choice D rationale: Confronting the abuser about concerning actions is not advisable as it can escalate the situation and put the client at greater risk.

Choice G rationale: Throwing away soiled clothing may destroy potential evidence and is not a priority intervention in the context of suspected elder mistreatment.

Choice H rationale: Querying the client in front of the suspected abuser can intimidate the client and prevent them from speaking freely about their situation.

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Correct Answer is B

Explanation

Choice A rationale

Explaining that every client will receive the same high level of care does not address the client's specific concerns about receiving care in accordance with their religion. It is important to recognize and respect individual preferences and beliefs in healthcare.

Choice B rationale

Asking the client about individual care preferences is the best action as it allows the nurse to understand and accommodate the client's specific religious needs and preferences. This approach demonstrates respect for the client's beliefs and promotes patient-centered care.

Choice C rationale

Consulting with a nurse who shares the same religious beliefs might provide some insight, but it is not the best approach. The client may have unique personal preferences that differ from general practices of their religion, so direct communication with the client is more effective.

Choice D rationale

Researching the religion on social media platforms is not a reliable or appropriate way to gather information about a client's care preferences. Social media may not provide accurate or comprehensive information, and personal preferences should be discussed directly with the client. .

A. Ask the client to describe the pain. B. Identify effective pain relief measures. C. Observe body language and movement. D. Provide a numeric pain scale.

Correct Answer is A

Explanation

Choice A rationale

Asking the client to describe the pain is the most effective way to assess the quality of pain. This approach allows the client to provide specific details about their pain experience, including the type, intensity, and characteristics, which are essential for accurate pain management.

Choice B rationale

Identifying effective pain relief measures is important but does not directly assess the quality of pain. This step is more focused on treatment rather than the initial assessment of pain quality.

Choice C rationale

Observing body language and movement can provide additional information about the pain but is not as reliable as directly asking the client. Nonverbal cues should supplement, not replace, the client's verbal report.

Choice D rationale

Providing a numeric pain scale helps quantify the intensity of pain but does not assess the quality. Quality assessment requires a descriptive approach to understand the nature of the pain fully.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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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.