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 C

Explanation

Choice A rationale:

Survivors of sexual assault can exhibit a wide range of psychological symptoms, and their experiences may vary significantly. There is no universal pattern of symptoms that applies to all survivors.

Choice B rationale:

Psychotherapy, such as trauma-focused cognitive-behavioral therapy, has been shown to be effective in helping survivors of sexual assault cope with and heal from their experiences.

Choice C rationale:

Rationale:

It is important to emphasize that sexual assault survivors often know the perpetrator, as this information dispels the myth that most assaults are committed by strangers.

Education should provide accurate and evidence-based information to address misconceptions.

Choice D rationale:

Survivors of sexual assault come from diverse backgrounds and living situations, and their marital status or residence in metropolitan areas is not universally applicable.

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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