A nurse is performing an admission assessment for an older adult client. The nurse should identify that which of the following findings is a manifestation of possible elder maltreatment?

The client has decreased muscle mass.

The client's eyes have white circles surrounding the cornea.

The client's clothes have a urine odor.

The client has nodules on the metacarpal joints.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Decreased muscle mass can be a normal age-related change in older adults and is not necessarily indicative of elder maltreatment.

Choice B rationale:

White circles surrounding the cornea (arcus senilis) is a common age- related finding and is not necessarily indicative of elder maltreatment.

Choice C rationale:

The presence of urine odor on the client's clothes could indicate neglect or inadequate care and should be further investigated.

Choice D rationale:

Nodules on the metacarpal joints may be related to osteoarthritis, which is a common condition in older adults and may not necessarily indicate elder maltreatment.

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Correct Answer is B

Explanation

Choice A rationale:

While wearing a supportive bra is generally advisable, wearing it 24 hours a day is not necessary and may cause discomfort.

Choice B rationale:

Performing a breast self-exam 1 week after menstruation is recommended for individuals with fibrocystic breast condition. Hormonal changes during the menstrual cycle can affect breast tissue, and examining the breasts when they are less likely to be affected by hormonal fluctuations can provide a more accurate baseline for self-examination.

Choice C rationale:

Mammograms are recommended more frequently than every 4 years, especially for those with fibrocystic breast condition or other risk factors.

Choice D rationale:

Increasing caffeine intake can exacerbate symptoms of fibrocystic breast condition. Caffeine is known to contribute to breast pain and tenderness.

A. Ensure padded wrist restraints are in the client's room. B. Initiate IV access for the client. C. Administer lorazepam every 4 hr to sedate the client. D. Place an incontinence brief on the client

Correct Answer is B

Explanation

Choice A rationale:

Padded wrist restraints are not appropriate unless there's a clear clinical indication to prevent self-harm or injury.

Choice B rationale:

After a seizure, it's important to establish IV access for the client to administer medications, fluids, or other interventions if needed. Monitoring for possible postictal state, airway patency, and vital signs are also important components of care.

Choice C rationale:

Administering lorazepam every 4 hours is not a standard protocol for post-seizure management and could lead to excessive sedation.

Choice D rationale:

Placing an incontinence brief is not necessary unless there's a specific indication, and it doesn't directly relate to post-seizure care.

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A nurse is performing an admission assessment for an older adult client. The nurse should identify that which of the following findings is a manifestation of possible elder maltreatment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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