A son brings his elderly mother to the emergency department and states that she fell today. The nurse notes multiple bruises in all stages of healing all over the client’s body. Which action should the nurse take first?.
Provide an elder abuse brochure and teach the client.
Interview the client privately and ask if anyone is harming her.
Observe the interaction between the mother and the son throughout stay.
Report the abuse without confirming
The Correct Answer is B
Interview the client privately and ask if anyone is harming her.
This is because the nurse has a duty to assess the client for possible elder abuse and report any suspicions to the appropriate authorities.
The nurse should not assume that the son is the abuser or that the client will disclose the abuse without being asked directly.
The nurse should also respect the client’s autonomy and privacy and not confront the son or provide an elder abuse brochure without the client’s consent.
Choice A is wrong because it may imply that the client is responsible for preventing the abuse or that the nurse has already made a judgment about the situation.
It may also be ineffective if the client is unable or unwilling to read the brochure or seek help. Choice C is wrong because it may delay the assessment and intervention for the client.
It may also be biased and unfair to observe the son without interviewing him or the client first.
Choice D is wrong because it may violate the client’s rights and preferences.
It may also be premature to report the abuse without confirming it with the client or obtaining more evidence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Self-determination. Self-determination is the ethical principle that respects the right of a person to make their own decisions. When a nurse respects the decision of a client who refuses a blood transfusion, the nurse is upholding this principle by acknowledging and protecting the client’s autonomy.
Choice A is wrong because beneficence is the ethical principle that involves actively seeking benefits or the promotion of good.
While a blood transfusion may be beneficial for the client, it is not the nurse’s role to impose their own judgment on the client’s choice.
Choice C is wrong because justice is the ethical principle that involves fairness and the just distribution of resources.
A blood transfusion is not a scarce resource that needs to be allocated among competing demands.
Choice D is wrong because fidelity is the ethical principle that involves keeping promises and being faithful to one’s commitments.
A blood transfusion is not a promise or a commitment that the nurse has made to the client.
Correct Answer is A
Explanation
“Have you had thoughts about killing yourself?” This is the best response because it directly assesses the client’s suicidal risk and shows empathy and concern.
The other choices are wrong because:
Choice B. “What can’t you go on anymore?” This is a vague and open-ended question that does not address the client’s immediate safety or emotional state.
Choice C. “Don’t think like that.
It’s not true!” This is a dismissive and invalidating response that does not acknowledge the client’s feelings or offer support.
Choice D. “Have you talked to your doctor about these feelings?” This is a deferring and avoiding response that does not explore the client’s situation or provide any intervention.
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