A public health nurse is assessing an older adult client who lives with a family member.
The nurse identifies several bruises in various stages of healing. The client and family members explain that the bruises are a result of clumsiness. However, based on the distribution of the bruises, the nurse suspects abuse.
Which of the following actions should the nurse take first?
Investigate further to confirm the suspicion.
Report the findings.
Provide the client with a crisis hotline number.
Discuss respite care with the client’s family.
The Correct Answer is B
The nurse has a legal and ethical obligation to report any suspected abuse of a vulnerable client, such as an older adult. Reporting the findings is the first action the nurse should take to protect the client and initiate an investigation by the appropriate authorities.
Choice A is wrong because investigating further to confirm the suspicion is not within the nurse’s scope of practice and could delay the reporting process.
Choice C is wrong because providing the client with a crisis hotline number is not enough to ensure the client’s safety and well-being.
The client might not be able to access the hotline or might be afraid to use it.
Choice D is wrong because discussing respite care with the client’s family is not appropriate at this stage.
The nurse should not assume that the family member is willing or able to provide adequate care for the client.
Respite care might be an option after the abuse is reported and investigated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Hypothermia is a condition where the body temperature drops below 35°C (95°F) and affects the normal functioning of the body. Elderly people are more at risk for hypothermia because they have a lower muscle mass, a decreased
shiver reflex, and lower immunity. They also tend to have a lower body temperature and may not develop fevers when they contract a viral or bacterial illness.
Choice B. Normothermia is wrong because it means having a normal body temperature, which is around 37°C (98.6°F).
Choice C. Hyperthermia is wrong because it means having a high body temperature, which is above 37.5°C (99.5°F).
Hyperthermia can be caused by heat exposure, infection, inflammation, or certain medications.
Choice D. Malignant hyperthermia is wrong because it is a rare genetic disorder that causes a severe reaction to certain anesthetics or muscle relaxants.
It is not related to thermoregulation in elderly people.
Question 5.
Correct Answer is C
Explanation
The client may have a ruptured appendix, which is a life-threatening complication of appendicitis. A ruptured appendix can cause peritonitis, which is an infection of the lining of the abdomen, or an abscess, which is a collection of pus around the appendix. These conditions require immediate medical attention and surgery to remove the appendix and clean the abdominal cavity.
Choice A is wrong because administering the prescribed medication may mask the symptoms of a ruptured appendix and delay diagnosis and treatment.
Choice B is wrong because repositioning the client and applying a heating pad may increase the risk of rupture or spread of infection.
Choice D is wrong because calling the operating room team is not the nurse’s responsibility and may not be feasible depending on the availability of the surgical team and the operating room.
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