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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Mucositis and diarrhea are side effects commonly associated with chemotherapy but are not directly related to myelosuppression. These symptoms are due to the impact of chemotherapy on rapidly dividing cells in the gastrointestinal tract.
B. Nausea and vomiting are common side effects of chemotherapy, primarily due to the treatment's impact on the gastrointestinal tract and the central nervous system.
C. Fever and chills are manifestations directly related to myelosuppression. Myelosuppression leads to a decrease in white blood cells (leukocytes), which compromises the immune system. This increased susceptibility to infection can result in symptoms such as fever and chills. These symptoms are indicative of potential infections or sepsis, which are more common in patients with compromised immune systems due to myelosuppression.
D. Alopecia (hair loss) and weight loss are common side effects of chemotherapy, but they are not directly related to myelosuppression. Alopecia results from the effects of chemotherapy on rapidly dividing hair follicle cells, while weight loss can be a consequence of changes in metabolism or appetite due to chemotherapy.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Myasthenia Gravis
Myasthenia Gravis (MG) is an autoimmune disorder characterized by weakness and rapid fatigue of voluntary muscles. Key features include fluctuating muscle weakness that typically worsens with activity and improves with rest, bilateral ptosis (drooping of the eyelids), and difficulty with swallowing and speaking. The fact that the client's facial muscle strength is better in the morning and worsens throughout the day is a hallmark of MG. The edrophonium (Tensilon) test is specifically used to diagnose MG by temporarily improving muscle strength.
Antibodies at the neuromuscular junction
Myasthenia Gravis is caused by the presence of autoantibodies that target acetylcholine receptors at the neuromuscular junction, leading to impaired communication between nerves and muscles. This is consistent with the described symptoms and the use of the edrophonium (Tensilon) test to diagnose the condition.
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