Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
The Correct Answer is []
Condition: Elder maltreatment 2 actions: Initiate a referral to adult protective services; Administer prescribed pain medication 2 parameters: Frequency and severity of bruises; Nutritional intake and weight
Rationale for correct condition The client’s physical signs (multiple bruises in various stages, unclean appearance), social indicators (dependency, financial control, food insecurity), and behavioral changes in the presence of the caregiver strongly suggest elder abuse. Elder maltreatment includes physical, emotional, financial, and neglectful harm. An 82-year-old with a BMI of 18.3 shows undernutrition. His improved demeanor away from the child reflects psychological coercion. Bruises in different stages may indicate repeated trauma over time.
Rationale for correct actions Referral to adult protective services ensures legal and social intervention and facilitates multidisciplinary evaluation for safety. Reporting is mandated and protects the client from further harm. Administering pain medication addresses acute injury (fracture of right radius) and helps restore comfort. Effective pain management is crucial for mobility and assessment of additional injuries.
Rationale for correct parameters Monitoring bruising patterns helps identify ongoing abuse and quantify recovery or new trauma. Repeated injuries in various healing stages are hallmark signs. Nutritional intake and weight reflect neglect; insufficient food intake leads to weight loss and reduced immune function. Tracking BMI and calorie intake can guide long-term recovery and support.
Rationale for incorrect conditions Osteoporosis-related fracture would more likely occur with minimal trauma and does not explain social neglect or emotional signs. Accidental fall may be plausible but lacks explanation for systemic neglect and coercion. Peripheral neuropathy doesn’t explain acute arm pain or psychosocial signs of neglect.
Rationale for incorrect actions Encouraging activity is inappropriate during acute fracture recovery and potential abuse. Bone density scans assess fragility but don’t address safety risks. Nutritional supplements may help but don’t resolve underlying maltreatment or acute injury.
Rationale for incorrect parameters Bone density is not immediately relevant and doesn't reflect maltreatment. Blood pressure fluctuations are not present and don’t indicate abuse. Grip strength cannot be assessed accurately with an arm fracture and isn't useful for abuse evaluation.
Take-home points • Elder maltreatment includes physical harm, neglect, emotional abuse, and financial exploitation • Victims may show improved responsiveness when abuser is absent • Multidisciplinary intervention via adult protective services is critical • Differentiation from accidental injury ensures proper protection and care
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Scant lochia rubra with a few small clots is a normal finding at 2 days postpartum. Lochia rubra, which is dark red discharge, is expected during the first 3-4 days. Scant bleeding and small clots are considered normal and indicate the uterine healing process is progressing appropriately. Excessive bleeding or large clots would be cause for concern.
Choice B rationale
Bilateral ankle edema is a common and expected finding at 2 days postpartum. This is due to the mobilization of fluid retained during pregnancy and the effects of gravity. While it should be monitored, it typically resolves on its own. The nurse should assess for other signs of a more serious condition, such as unilateral leg swelling, pain, or redness, which could indicate a deep vein thrombosis.
Choice C rationale
A urine output of 2,500 mL/day is within the expected range for a postpartum client. Diuresis is a normal physiological process during the first few days after birth, as the body eliminates the excess fluid volume accumulated during pregnancy. Urine output typically ranges from 2,000 to 3,000 mL/day, indicating adequate kidney function and fluid mobilization.
Choice D rationale
Deep-tendon reflexes of 4+ are a hyperreflexic finding that can indicate a neurological complication, such as preeclampsia. Normal deep-tendon reflexes are typically 1+ to 2+. Hyperreflexia is a sign of central nervous system irritability and can precede seizure activity, making it a critical finding that requires immediate reporting to the provider for further assessment and intervention. .
Correct Answer is B
Explanation
Choice A rationale
Administering a vasoconstrictor is a potential intervention for shock but it is not the first action. The client's hypotension and tachycardia are indicative of hypovolemic shock due to profuse vomiting, leading to fluid loss. The body's initial compensatory mechanism involves vasoconstriction to maintain blood pressure, so further constriction without addressing the volume deficit can worsen tissue perfusion.
Choice B rationale
The client is exhibiting signs of hypovolemic shock, including a low blood pressure of 86/58 mmHg, a high pulse of 114/min, and a high respiratory rate of 27/min. These are physiological compensations for reduced circulating blood volume. Increasing the intravenous infusion rate directly addresses the primary problem by rapidly replacing lost fluid volume, thereby increasing preload, stroke volume, cardiac output, and ultimately, blood pressure.
Choice C rationale
Elevating the client's feet can temporarily increase venous return to the heart and improve blood pressure. However, this is a passive measure that does not address the underlying fluid deficit causing the hypovolemic shock. It is a helpful adjunctive action but is not the definitive first-line intervention required to correct the circulatory collapse in this scenario.
Choice D rationale
Initiating oxygen therapy is a supportive measure for shock because it helps improve tissue oxygenation, which is compromised due to poor perfusion. While beneficial, it does not correct the root cause of the shock, which is the lack of circulating fluid volume. The most immediate and life-saving intervention is to restore fluid volume to improve cardiac output and blood pressure
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