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. This statement is relevant to the patient's health but does not indicate a need for further action by the nurse. Omeprazole is a common medication for acid reflux.
B. This statement is appropriate for patients with asthma. Fluticasone is a maintenance inhaler used to prevent asthma attacks, and taking it regularly as prescribed is important.
C. This statement is correct. Albuterol is a quick-relief inhaler used to treat asthma attacks.
D. This statement indicates a potential interaction with the patient's asthma medications. Beta-blockers like metoprolol can worsen asthma symptoms in some patients. The nurse should discuss this with the patient's doctor to determine if the benefits of metoprolol outweigh the risks for this individual.

A. "It develops due to an autoimmune reaction after a recent infection." B. "The exact cause is unknown, but it's thought to involve a combination of genetics and environmental factors." C. "The cause is thought to be reactivation of a virus in cranial nerve VII." D. "It is caused by demyelination of nerves in the brain and spinal cord."

Correct Answer is B

Explanation

A. Parkinson's disease is not generally considered to be caused by an autoimmune reaction or a recent infection. Autoimmune reactions leading to neurodegeneration are more commonly associated with other conditions such as multiple sclerosis, not Parkinson's disease.
B. The exact cause of Parkinson's disease is indeed unknown, but research suggests that it results from a combination of genetic predispositions and environmental factors. Genetic mutations may contribute to the development of Parkinson's disease in some individuals, while environmental factors such as exposure to certain toxins or other external influences might also play a role. The interplay between these factors is still being studied.
C. There is no evidence to support the idea that Parkinson's disease is caused by the reactivation of a virus affecting cranial nerve VII (the facial nerve). Parkinson's disease involves the degeneration of dopamine-producing neurons in the brain, not specifically related to viral reactivation or isolated to cranial nerve VII.
D. Demyelination of nerves is characteristic of multiple sclerosis, not Parkinson's disease. In Parkinson's disease, the primary issue is the loss of dopamine-producing neurons in the substantia nigra of the brain, not demyelination. This option describes a different pathological process unrelated to Parkinson's disease.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a clinic is reviewing the home medications of client who has a history of asthma, and who is at the clinic to have a routine annual physical. Which statement made by the patient would indicate a need for further action by the nurse?

Correct Answer is D

Explanation

A client who has a new diagnosis of Parkinson's Disease asks the nurse "Why did I develop this disease? What caused it?" Which response should the nurse provide?

Correct Answer is B

Explanation

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