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.

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

The HOPE Tool for spiritual assessment is a questionnaire that explores the sources of hope, meaning, comfort, strength, peace, love, and connection for patients in healthcare settings. It does not ask about the correctness of one’s belief, but rather about the relevance and importance of one’s spirituality to one’s overall health and well-being. Therefore, choice B is not part of the HOPE Tool.

Choice A is wrong because it is part of the HOPE Tool. It asks about the personal spirituality and practices of the patient.

Choice C is wrong because it is part of the HOPE Tool. It asks about the organized religion or spiritual community of the patient.

Choice D is wrong because it is part of the HOPE Tool. It asks about the sources of hope or sustenance for the patient.

Normal ranges are not applicable to this question as it is not a numerical or quantitative measure.

A. The teenager is probably difficult for a single mother to manage, so the family will be referred to social services. B. Further assessment needs to be done to determine if the family needs assistance. C. The mother needs assistance to cope with the stress of raising a teenager on her own. D. The mother will need financial support while she takes off work to care for her son.

Correct Answer is B

Explanation

This is because the nurse should not make assumptions about the family’s functionality based on their history or situation, but rather gather more information to identify their strengths and needs.

Choice A is wrong because it implies that the teenager is a problem and the mother is incapable of managing him, which is disrespectful and judgmental.

Choice C is wrong because it assumes that the mother is stressed and needs coping skills, which may not be true.

Choice D is wrong because it suggests that the mother is financially dependent on her son, which is not relevant to the question.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The RN learns that the father of a teenage client was killed in a car accident when he was a baby, and his mother has raised him on her own. How should the nurse interpret this family’s functionality?

Correct Answer is B

Explanation

While preparing a client for surgery, the nurse marks the arm that is to be amputated and participates in a “time-out” procedure before the surgery begins. Which sentinel event is this action intended to prevent?

An elderly client is hospitalized for the first time. Which of the following actions ensures the safety of the client? (Select all that apply).

The nurse educator is presenting information to a group of nursing students regarding uninsured and underinsured clients. The nurse educator emphasizes that a lack of insurance or lack of sufficient insurance is:

A nurse is utilizing the cognitive domain of learning to teach a patient about the prevention of inflammation. Which of the following is an appropriate goal for this patient?

A person with anemia is prescribed erythropoietin subcutaneously. The nurse knows that erythropoietin:

Which thermoregulatory condition is an elderly person most at risk for?

Your patient was outdoors and developed hypothermia. You know that independent nursing interventions would include:

The nurse is assigned to care for a client admitted to the hospital with chronic obstructive pulmonary disease (COPD). Which medication does the nurse anticipate to decrease this client’s risk for developing a respiratory infection?