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 A
Explanation
Choice A rationale
An acute hemolytic transfusion reaction is a severe and life-threatening reaction caused by an incompatibility between the donor's blood and the client's blood. The recipient's antibodies attack and destroy the transfused red blood cells, leading to hemolysis. The classic symptoms include chills, fever, low-back pain, tightness in the chest, and headache. This reaction is a medical emergency requiring immediate cessation of the transfusion and supportive care.
Choice B rationale
An allergic reaction to a blood transfusion is typically caused by the recipient's antibodies reacting to a foreign plasma protein in the donor blood. Symptoms can range from mild, such as hives and itching, to severe, such as anaphylaxis. However, symptoms like low-back pain and a feeling of "tightness" in the chest are more characteristic of a hemolytic reaction rather than a simple allergic response.
Choice C rationale
A febrile nonhemolytic transfusion reaction is the most common type of transfusion reaction. It is caused by the recipient's antibodies reacting to donor white blood cells. Symptoms include fever and chills, but typically do not include the severe manifestations of low-back pain, headache, and chest tightness that are seen in a hemolytic reaction. The reaction is usually not life-threatening.
Choice D rationale
Transfusion-related acute lung injury (TRALI) is a serious and potentially fatal complication of a transfusion. It is characterized by the sudden onset of non-cardiogenic pulmonary edema within six hours of a transfusion. Symptoms primarily involve respiratory distress, such as dyspnea and hypoxemia. While TRALI is severe, the symptoms presented, particularly the low-back pain and chest tightness, are more indicative of an acute hemolytic reaction. .
Correct Answer is A
Explanation
Choice A rationale
The first step in inserting an indwelling urinary catheter, after gathering supplies and preparing the client, is to lubricate the tip. The application of a generous amount of water-soluble gel to the catheter tip reduces friction as it passes through the urethra. This is crucial for minimizing trauma to the urethral mucosa and decreasing client discomfort during insertion.
Choice B rationale
Positioning the sterile drape is a later step in the procedure, after the catheter has been prepared for insertion. The drape is used to create a sterile field and isolate the perineum. This helps prevent contamination of the sterile catheter and gloves from surrounding non-sterile areas, which is essential for maintaining sterility and preventing infection.
Choice C rationale
Cleansing the meatus with an antiseptic solution is a critical step, but it is performed after the catheter is lubricated and the sterile field is established. This action mechanically and chemically removes microorganisms from the perineal area, reducing the risk of introducing bacteria into the urinary tract during catheter insertion.
Choice D rationale
Attaching a prefilled syringe to the inflation hub is done after the catheter is fully inserted into the bladder and urine flow is established. This step is necessary to inflate the balloon, which secures the catheter in place and prevents it from being expelled. Doing this prematurely could cause urethral damage. *.
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