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 C

Explanation

A. "I will soak my feet in warm water every night.": Soaking feet can lead to skin maceration and increase the risk of infection, particularly in clients with diabetes who may have peripheral neuropathy or impaired circulation. Safe foot care recommends washing and gently drying feet without prolonged soaking.

B. "I will apply a moisturizing cream between my toes.": Applying moisturizer between the toes can create a moist environment that promotes fungal infections. Moisturizing should be limited to dry areas of the feet, avoiding skin folds and interdigital spaces.

C. "I will be sure to wear cotton socks.": Cotton socks help absorb moisture, reduce friction, and prevent excessive sweating, which lowers the risk of skin breakdown and infection. Proper sock choice is a key component of daily diabetic foot care and protects against ulcer formation.

D. "I will buy new shoes in the early morning hours.": Feet typically swell during the day, so shoes should be purchased later in the day when feet are at their largest. Buying shoes in the morning may result in footwear that is too tight and increases the risk of pressure sores or blisters.

A. Document the client's respiratory rate in 1 hr. B. Monitor the client for an allergic reaction for 30 min. C. Check the client's response to the medication in 1 hr. D. Evaluate the client for therapeutic effects in 30 min.

Correct Answer is A

Explanation

A. Document the client's respiratory rate in 1 hr: Measuring and recording vital signs, including respiratory rate, is within the scope of practice for an assistive personnel (AP). After the nurse administers a PRN pain medication, the AP can safely monitor and document routine parameters, providing the nurse with data to evaluate the client’s response.

B. Monitor the client for an allergic reaction for 30 min: Observing for adverse or allergic reactions requires nursing assessment skills, clinical judgment, and the ability to intervene immediately if a severe reaction occurs. This task is outside the AP’s scope of practice.

C. Check the client's response to the medication in 1 hr: Evaluating a client’s pain relief or therapeutic response involves subjective assessment and interpretation, which require nursing judgment. This responsibility cannot be delegated to an AP.

D. Evaluate the client for therapeutic effects in 30 min: Assessing the effectiveness of medication, such as pain relief or sedation, requires clinical judgment and decision-making to determine if further interventions are needed. This is a nursing responsibility and should not be assigned to an AP.

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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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