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 theft to the police may be necessary, the immediate concern is the safety and well-being of the client, especially if financial exploitation or abuse is suspected.
B.   Report the possible abuse to adult protective services: Suspected financial exploitation or abuse of an older adult should be reported to the appropriate authorities, such as adult protective services, for investigation and intervention.
C.   Ask the client if there is another family member they can call for financial help: While involving other family members may be appropriate in some situations, suspected abuse or exploitation requires intervention from trained professionals.
D.   Restrict visitation for the client's family until discharge: Restricting visitation should only be done if there is a clear risk to the client's safety, and it should not be the first action taken in response to suspected abuse.

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Correct Answer is A

Explanation

A. A decreased level of consciousness and vomiting may indicate a potentially serious condition such as increased intracranial pressure, electrolyte imbalance, or metabolic disorder. Immediate assessment and intervention are necessary to determine the cause and provide appropriate treatment.
B. Cellulitis accompanied by a low-grade fever is concerning but may not require immediate attention compared to a decreased level of consciousness and vomiting.
C. A pain rating of 7 after receiving analgesia 30 minutes ago is important to address, but it may not be as urgent as assessing a client with a decreased level of consciousness and vomiting.
D. A blood glucose level of 160 mg/dL in a client with type 2 diabetes mellitus may require monitoring and intervention, but it may not be as urgent as assessing a client with a decreased level of consciousness and vomiting.

A. Switch to a soy-based formula. B. Switch to a goat's milk formula. C. Switch to an unpasteurized milk formula. D. Switch to a condensed milk formula.

Correct Answer is A

Explanation

A. Switch to a soy-based formula: Bloody stools in infants can be indicative of a cow's milk protein allergy or intolerance. Switching to a soy-based formula may alleviate symptoms in such cases.
B. Switch to a goat's milk formula: Goat's milk is not recommended for infants as it lacks essential nutrients and can lead to nutritional deficiencies and other health issues.
C. Switch to an unpasteurized milk formula: Unpasteurized milk poses a risk of bacterial contamination and is not recommended, especially for infants who are more susceptible to infections.
D. Switch to a condensed milk formula: Condensed milk is not suitable as a primary source of nutrition for infants and does not address the potential underlying issue of cow's milk intolerance.

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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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Explanation

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