A nurse is caring for an older adult client who states, "I can't pay for my care because my kid took all my money." Which of the following actions should the nurse take?

Instruct the client to report the theft to the police.

Report the possible abuse to adult protective services.

Ask the client if there is another family member they can call for financial help.

Restrict visitation for the client's family until discharge.

Answer and Explanation

The Correct Answer is B

A. Instruct the client to report the theft to the police: While reporting to law enforcement is an option, the client may feel intimidated or unsafe doing so, and immediate protection and assessment of the situation are more urgent. The nurse’s priority is ensuring safety and initiating appropriate protective services.

B. Report the possible abuse to adult protective services: Financial exploitation is a form of elder abuse. Nurses are mandated reporters and should notify adult protective services to investigate and intervene as needed. This ensures the client’s safety, prevents further exploitation, and connects them with resources for protection and support.

C. Ask the client if there is another family member they can call for financial help: While exploring support systems is important, relying on another family member without assessment may not address potential abuse and does not fulfill the nurse’s legal obligation to report suspected exploitation.

D. Restrict visitation for the client's family until discharge: Restricting visitation may limit contact temporarily, but it does not address the underlying abuse or ensure ongoing protection. Reporting to protective services provides a structured and legal mechanism for safeguarding the client.

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Correct Answer is D

Explanation

A. A client who is exhibiting flight of ideas: Flight of ideas indicates pressured, rapid speech and distractibility often seen in mania. While this requires monitoring and support, it does not pose an immediate risk of harm to the client or others.

B. A client who refuses to attend group therapy: Refusal to attend therapy reflects a non-urgent behavioral issue. The client’s autonomy should be respected, and interventions can be planned after more urgent concerns are addressed.

C. A client who is experiencing a moderate level of anxiety: Moderate anxiety may cause discomfort and decreased coping, but it does not typically create an immediate threat to safety. The nurse can intervene with calming techniques and support in a timely manner.

D. A client who is having command hallucinations: Command hallucinations can instruct the client to harm themselves or others, representing an immediate safety risk. The nurse should assess this client first to implement interventions that prevent potential harm and ensure safety on the unit.

A. Avoiding actions that can cause harm to the client B. Prioritizing interventions that benefit the client C. Allowing the client to function independently D. Being honest with the client

Correct Answer is D

Explanation

A. Avoiding actions that can cause harm to the client: This action demonstrates the ethical principle of nonmaleficence, which focuses on preventing harm, rather than veracity. While important in nursing practice, it does not relate specifically to truthfulness.

B. Prioritizing interventions that benefit the client: This reflects the principle of beneficence, which emphasizes doing good and promoting the client’s well-being. It does not directly involve honesty or truthful communication with the client.

C. Allowing the client to function independently: Supporting autonomy involves respecting the client’s ability to make decisions and perform activities independently. While ethically important, it is not the same as veracity.

D. Being honest with the client: Veracity refers to truthfulness and providing accurate, complete information to clients. Being honest about diagnoses, treatments, and care plans ensures informed decision-making and builds trust between the nurse and client.

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A nurse is caring for an older adult client who states, "I can't pay for my care because my kid took all my money." Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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