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 C
Explanation
The role of the risk manager is to identify and analyze the factors that contributed to the adverse event and to implement strategies to prevent or reduce the likelihood of recurrence. The risk manager is not concerned with assigning blame or protecting the staff from litigation, but rather with improving the quality and safety of care.
Choice A is wrong because it implies a punitive approach that does not address the underlying system issues.
Choice B is wrong because it suggests a defensive attitude that does not foster a culture of learning and improvement.
Choice D is wrong because it assumes that the nurses were not aware of the patient’s fall risk, which may not be the case.
The risk manager should investigate all aspects of the situation, including the communication and documentation of the patient’s fall risk assessment and interventions.
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.
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