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 B
Explanation
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.
Correct Answer is A
Explanation
Some of the symptoms of heat stroke are:
• High body temperature of 104 F (40 C) or higher
• Altered mental state or behavior, such as confusion, agitation, slurred speech, seizures or coma
• Lack of sweating despite the heat
• Red, hot and dry skin
• Rapid and strong pulse
• Throbbing headach
• Nausea and vomiting
Choice B is wrong because it is necessary to call 911 if someone has heat stroke. Heat stroke is a medical emergency that requires immediate attention and cooling of the body.
Choice C is wrong because it is not normal to vomit and not sweat during a marathon. Vomiting and lack of sweating are signs of dehydration and heat stroke, which indicate that the body is unable to regulate its temperature properly.
Choice D is wrong because getting the patient to a cooler, air-conditioned place will not reverse the heat exhaustion.
Heat exhaustion is a milder form of heat-related illness that can lead to heat stroke if not treated. Heat exhaustion symptoms include heavy sweating, weakness, dizziness, nausea and muscle cramps. Getting the patient to a cooler place may help with heat exhaustion, but heat stroke requires more aggressive cooling measures such as immersing the patient in cold water or applying ice packs to the body.
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