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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Giving a report to a provider in SBAR format is not related to one of the National Patient Safety Goals (NPSGs). The NPSGs are a set of standards developed by The Joint Commission to improve patient safety andquality of care. They address specific areas of concern such as infection prevention, medication safety, patient identification, communication, and alarm management.
Choice A is wrong because refraining from changing alarm settings is related to NPSG 06.01.01, which aims to improve the safety of clinical alarm systems. Choice B is wrong because using 2 patient identifiers for medication administration is related to NPSG 01.01.01, which aims to improve the accuracy of patient identification.
Choice D is wrong because arriving 15 minutes prior to the start of the shift is related to NPSG 02.03.01, which aims to improve the effectiveness of communication among caregivers.
Correct Answer is A
Explanation
The Nurse Practice Act is a law that outlines the legal scope of practice for nursing in each state. It defines the roles, functions, responsibilities and activities that a nurse is educated, competent and authorized to perform. The Nurse Practice Act also establishes the regulatory bodies that create and implement rules and regulations to protect the public.
Choice B. Nursing process is wrong because it is a systematic method of providing nursing care, not a legal document that defines the scope of practice.
Choice C. Code of Ethics is wrong because it is a set of principles that guide the moral and professional conduct of nurses, not a legal document that defines the scope of practice.
Choice D. Facility policies and procedures are wrong because they are specific guidelines for each healthcare organization, not a legal document that defines the scope of practice.
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