A nurse is conducting a home health visit for an older adult client who lives with family members. The nurse notices that the client has multiple unusual bruises, and, based on several other factors, the nurse suspects that the client has been physically abused. Which of the following actions should the nurse take first?
Check the bruises at the next visit to the client's home.
Follow the agency's guidelines for reporting suspected abuse.
Institute more frequent visits to the client's home.
Arrange referral for family therapy to deal with home stressors.
The Correct Answer is B
A. Checking the bruises at the next visit may delay necessary intervention. If abuse is suspected, immediate action, such as reporting, is essential to protect the client.
B. Following the agency's guidelines for reporting suspected abuse is the priority when abuse is suspected. Reporting abuse to the appropriate authorities, such as adult protective services or law enforcement, is crucial to ensure the safety and well-being of the older adult.
C. Instituting more frequent visits to the client's home might be part of a safety plan, but it should not be the first action. Reporting suspected abuse is the priority to involve the appropriate authorities.
D. Arranging a referral for family therapy is not the first step in suspected elder abuse. Safety and protection of the older adult take precedence. Once the immediate safety concerns are addressed, additional interventions, such as family therapy, may be considered.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hyperexcitability is not typically associated with major depressive disorder. In fact, individuals with depression often experience a decrease in energy, motivation, and overall activity levels.
B. Significant change in weight.
Major depressive disorder (MDD) is often associated with changes in appetite and weight. Clients with MDD may experience either weight loss or weight gain. This can result from changes in eating habits related to the individual's emotional state.
C. Exaggerated response of pleasure to stimuli is not a characteristic finding in major depressive disorder. In contrast, individuals with depression may experience anhedonia, which is a reduced ability to experience pleasure from previously enjoyable activities.
D. Attention-seeking behavior is not a specific characteristic of major depressive disorder. Individuals with depression may withdraw socially and experience difficulties in concentration and attention.
Correct Answer is C
Explanation
A. Identification: Identification involves taking on the characteristics of another person, group, or entity. The client's response is not an example of identification.
B. Relation-formation: This term is not a recognized defense mechanism in the context of classical psychoanalytic theory. It seems to be a combination of two concepts but doesn't fit the context of the client's statement.
C. Projection
Projection is a defense mechanism where an individual attributes their own unacceptable thoughts, feelings, or impulses to another person. In this scenario, the client is projecting their own feelings of anger and a desire to have a drink onto the nurse and others, suggesting that the staff is angry at them and wants to go out for a drink.
D. Compensation: Compensation involves making up for a perceived weakness by emphasizing a strength in another area. The client's statement do
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