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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Maternal hemoglobin and hematocrit levels are important indicators of the mother's health but are not direct indicators of fetal well-being.
Choice B rationale:
A Coombs test is performed on newborns to assess for hemolytic disease, not to monitor fetal well-being.
Choice C rationale:
A biophysical profile assesses multiple parameters of fetal well-being, including fetal heart rate, fetal movement, fetal breathing, amniotic fluid volume, and fetal tone.
Choice D rationale:
An alpha-fetoprotein test is a screening test for neural tube defects and chromosomal abnormalities but is not typically used to monitor fetal well-being in hypertensive pregnancies.
Correct Answer is B
Explanation
Choice A rationale:
Asking who the client talks to when overwhelmed is important, but assessing for suicidal thoughts is more urgent.
Choice B rationale:
Assessing the client's risk for harm to themselves is the priority when dealing with a person in crisis. This helps determine the need for immediate intervention to ensure their safety.
Choice C rationale:
Discussing the impact of the partner's death can be therapeutic, but ensuring immediate safety is the priority.
Choice D rationale:
Inquiring about coping strategies is important, but assessing for suicidal thoughts takes precedence.
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