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.
The Correct Answer is B
The nurse should report the possible abuse to adult protective services if an older adult client states that their child took all their money. This is an important nursing intervention to ensure the safety and well-being of the client.
a) Instructing the client to report the theft to the police may be appropriate, but it is not the first action the nurse should take. The nurse has a legal and ethical obligation to report suspected abuse to the appropriate authorities.
c) Asking the client if there is another family member they can call for financial help may be appropriate, but it does not address the issue of possible abuse.
d) Restricting visitation for the client's family until discharge is not appropriate and may violate the client's rights.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Answer: (C) The client is not grimacing
Rationale:
A) The client's blood pressure has been reduced:
While morphine can lower blood pressure due to its vasodilatory effects, a reduction in blood pressure is not necessarily a primary indicator of a therapeutic response to pain relief. It is more important to assess pain relief directly through the client's subjective experience and behavior rather than focusing on vital signs alone.
B) The client exhibits diaphoresis:
Diaphoresis, or sweating, can occur as a side effect of morphine administration but does not indicate that the medication is effectively relieving pain. In fact, diaphoresis might signal an adverse reaction or discomfort rather than a therapeutic effect.
C) The client is not grimacing:
The absence of grimacing suggests that the client's pain has decreased, which is a direct indicator of a therapeutic response to morphine. Observing a reduction in pain-related behaviors, such as grimacing, is a key assessment for determining the effectiveness of pain management in postoperative clients.
D) The client has an elevated heart rate:
An elevated heart rate may be a sign of unresolved pain or a side effect of morphine but is not a clear indicator of pain relief. Effective pain management with morphine typically results in a decrease in sympathetic nervous system responses, such as a high heart rate, rather than an increase.
Correct Answer is B
Explanation
Applying heat to the affected joints can help relieve pain and stiffness ¹. A heating pad or warm compress
can be used to apply heat to the hands.
The other options are not correct because:
a) Sleeping on a soft mattress is not mentioned as a way to manage osteoarthritis symptoms.
b) spirin should be taken with food or milk to reduce stomach irritation .
c) Exercising inflamed joints excessively can worsen symptoms. It is important to balance rest and activity.
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