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
Fluid volume excess is wrong because appendicitis does not cause fluid retention or overload. It may cause fluid loss due to vomiting, fever, or rupture of the appendix. Therefore, a more appropriate nursing diagnosis would be the risk for deficient fluid volume.
Choice B. Risk for infection is correct because appendicitis is an inflammatory condition that can lead to bacterial infection, especially if the appendix ruptures and causes peritonitis or abscess formation.
Choice C. Ineffective thermoregulation is correct because appendicitis can cause fever due to inflammation and infection.
Choice D. Pain is correct because appendicitis causes acute abdominal pain that usually starts in the periumbilical area and then localizes to the right lower quadrant. The pain may be accompanied by nausea, vomiting, and rebound tenderness.
Correct Answer is A
Explanation
This demonstrates advocacy for client rights because it respects the client’s autonomy, dignity, and preferences. It also helps the client to make informed decisions about their own health.
Choice B is wrong because telling the client that refusal of the medication is considered noncompliance is coercive and violates the client’s right to refuse treatment.
It also does not address the client’s reasons for refusing the medication or provide any information or education.
Choice C is wrong because informing the client that the medication is the same as taken at home is not enough to ensure that the client understands the purpose, benefits, and risks of the medication.
It also does not verify that the client is taking the medication correctly at home or that there are no changes in the dosage or frequency.
Choice D is wrong because insisting the client takes the prescribed medications is also coercive and violates the client’s right to refuse treatment.
It also does not respect the client’s autonomy, dignity, and preferences.
It may also cause harm to the client if they have an allergy, intolerance, or contraindication to the medication.
Advocacy for nursing stems from a philosophy of nursing in which nursing practice is the support of an individual to promote his or her own well-being, as understood by that individual. It is an ethic of practice that requires nurses to protect and uphold their patients’ rights, values, and interests.
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