An older adult client is brought to an urgent care clinic by her paid in-home caregiver for a suspected UTI. The client has bruising to the left side of her face and appears fearful when her caregiver makes sudden movements. Which priority action should the nurse take first?

Notify adult protective services about possible elder abuse by the caregiver.

Have the caregiver stay in the waiting area while the client is brought into a room for assessment.

Contact the caregiver's employment agency to report the suspicion of abuse.

Ask the patient how the injury occurred and observe the caregiver's reaction.

Answer and Explanation

The Correct Answer is B

A.   This action is crucial if there is a suspicion of elder abuse, as adult protective services (APS) can investigate the situation thoroughly and take necessary measures to protect the client. However, before making such a notification, it is important to assess the immediate safety of the client and gather preliminary information.
B.   This is a prudent initial action to ensure that the client is in a safe environment away from the caregiver, who may be the suspected abuser. It allows the nurse to conduct a private and thorough assessment of the client without the potential influence or intimidation from the caregiver. This step is critical for ensuring the client's safety and obtaining unbiased information.
C.   While reporting to the caregiver’s employment agency may be a step in the process, it is not the immediate priority. The primary focus should be on ensuring the client’s safety and assessing the situation before contacting external agencies.
D.   While it is important to gather information about how the injury occurred, the immediate priority is to ensure the client's safety and provide an opportunity for a private assessment. The presence of the caregiver during this conversation could influence the client's responses or cause additional stress.

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Correct Answer is D

Explanation

A. Phacoemulsification is a procedure used to remove cataracts from the eye. It involves using ultrasound waves to break up the cloudy lens (cataract) into small fragments, which are then suctioned out. While this procedure is relevant for cataract treatment, it does not address the acute management of angle-closure glaucoma.
B. Extracapsular cataract extraction is a surgical procedure to remove a cataract from the eye by making an incision and extracting the lens in one piece or in large segments. Like phacoemulsification, this procedure is focused on cataract removal and does not directly treat the underlying issue of acute angle-closure glaucoma.
C. A cochlear implant is a device used to provide a sense of sound to individuals with severe hearing loss or deafness. This procedure is unrelated to the treatment of eye conditions or intraocular pressure and therefore is not appropriate for managing primary angle-closure glaucoma.
D. Surgical iridectomy is a procedure specifically aimed at treating angle-closure glaucoma. It involves creating a small hole (iridectomy) in the peripheral iris to allow aqueous humor to flow from the posterior chamber of the eye to the anterior chamber, bypassing the obstructed drainage angle.

A. "It is caused by the overproduction of T3, T4, and calcitonin by the thyroid gland." B. "It is caused by the lack of production of adrenocorticotropic hormone by the pituitary gland." C. "It is caused by the lack of production of thyroid stimulating hormone by the pituitary gland." D. "It is caused by the lack of production of aldosterone by the adrenal gland."

Correct Answer is C

Explanation

A. Secondary hypothyroidism is characterized by insufficient production of thyroid hormones (T3 and T4) due to inadequate stimulation from the pituitary gland, not due to overproduction. Overproduction of thyroid hormones would typically be associated with hyperthyroidism, not hypothyroidism.
B. Adrenocorticotropic hormone (ACTH) stimulates the adrenal glands to produce cortisol. A deficiency in ACTH would lead to adrenal insufficiency or Addison's disease, not secondary hypothyroidism.
Secondary hypothyroidism specifically involves a deficiency in thyroid-stimulating hormone (TSH), not ACTH.
C. Secondary hypothyroidism is caused by inadequate production of thyroid-stimulating hormone (TSH) by the pituitary gland. TSH is necessary for stimulating the thyroid gland to produce thyroid hormones (T3 and T4). When the pituitary gland does not produce enough TSH, the thyroid gland is not adequately stimulated, leading to low levels of thyroid hormones in the blood.
D. Aldosterone is a hormone produced by the adrenal glands that helps regulate sodium and potassium levels, as well as blood pressure. A deficiency in aldosterone is associated with conditions such as
Addison’s disease or primary adrenal insufficiency, not secondary hypothyroidism. Secondary
hypothyroidism specifically relates to issues with TSH production, not aldosterone.

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An older adult client is brought to an urgent care clinic by her paid in-home caregiver for a suspected UTI. The client has bruising to the left side of her face and appears fearful when her caregiver makes sudden movements. Which priority action should the nurse take first?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A staff nurse is teaching a client who has secondary hypothyroidism about the disease process. The client asks the nurse what causes secondary hypothyroidism. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

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