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Exhibits

The client has started to wake up more, opening her eyes without stimulation and looking around the room.

Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.

Assess the client's pain

Increase the propofol infusion

Notify the social worker the client is awake.

Have the client sign consent forms for procedures already performed

Consider extubating the client

Determine the client's decision-making ability

Decrease the noise and light stimuli in the room as much as possible

Explain all procedures

Answer and Explanation

Correct Answer : A,F,G,H

A. Assess the client's pain: The client has experienced significant trauma, undergone surgery, and may be in pain or discomfort as she regains consciousness. Pain assessment is crucial for adequate pain management and to prevent agitation or hemodynamic instability.
B. Increase the propofol infusion: Increasing sedation should not be the first response. Instead, assess the client’s pain and agitation, and if necessary, adjust sedation based on clinical need and provider recommendations.
C. Notify the social worker the client is awake: A social worker may be involved in care planning, but waking up does not require immediate notification.
D. Have the client sign consent forms for procedures already performed: If the client was incapacitated at the time of previous procedures, consent was likely obtained from a legal surrogate. Retroactive consent is not legally valid.
E. Consider extubating the client: The decision to extubate should be based on respiratory assessments, arterial blood gas (ABG) results, and overall stability, not just the client waking up.
F. Determine the client’s decision-making ability: As the client becomes more aware, it is important to assess cognitive function and orientation to determine if she can participate in decisions regarding her care. If the client is alert and coherent, she may be able to provide informed consent for further treatments.
G. Decrease the noise and light stimuli in the room as much as possible: Critically ill patients can become disoriented and agitated as they wake up. A calm environment helps reduce stress and delirium, improving recovery and promoting rest.
H. Explain all procedures: The client is waking up in an unfamiliar environment (intubated in the ICU), which can be frightening and disorienting. Explaining procedures provides reassurance and can help reduce anxiety and agitation.

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Correct Answer is A

Explanation

A: Starting with less sensitive questions allows the nurse to build rapport and establish trust with the client, making it easier for them to disclose more sensitive information about possible abuse.

B: Asking vague, non-specific questions may confuse the client and hinder open communication. Clear, respectful questioning is necessary.

C: Getting difficult questions out of the way may overwhelm the client and discourage disclosure of abuse.

D: Sharing personal values can lead to judgmental interactions and may not put the client at ease. A neutral, nonjudgmental approach is key.

A. Report findings to Adult Protective Services. B. Perform a thorough physical assessment. C. Confront the abuser about concerning actions. D. Develop a safety plan. E. Question the client in front of the suspected abuser. F. Take photographs to document the abuse or neglect. G. Throw away soiled clothing. H. Complete a comprehensive history.

Correct Answer is ["A","B","D","F","H"]

Explanation

A. Report findings to Adult Protective Services: Reporting to Adult Protective Services (APS) is essential when elder mistreatment is suspected. APS can investigate the situation further and take appropriate action to ensure the safety and well-being of the elder.
B. Perform a thorough physical assessment: Conducting a thorough physical assessment helps to identify any signs of abuse or neglect, such as pressure injuries, poor hygiene, or physical injuries. It provides necessary information to support the suspicion of mistreatment.
C. Confront the abuser about concerning actions: Confronting the abuser directly can be dangerous for the client and may interfere with the investigation. It is best to report concerns to appropriate authorities who can handle the situation professionally.
D. Develop a safety plan: Developing a safety plan is crucial to protect the client from immediate harm. This plan includes steps to ensure the client’s safety and well-being while further actions are being taken.
E. Question the client in front of the suspected abuser: Questioning the client in front of the suspected abuser could put the client at further risk of harm. It is important to ensure the client’s safety and privacy when gathering information.
F. Take photographs to document the abuse or neglect: Documenting findings through photographs can provide evidence of abuse or neglect, which is important for reporting and investigation purposes. This documentation should be done with caution and respect for privacy.
G. Throw away soiled clothing: Disposing of soiled clothing does not address the underlying issue of mistreatment and may destroy potential evidence. Soiled clothing should be documented and handled appropriately.
H. Complete a comprehensive history: Completing a comprehensive history helps to gather detailed information about the client’s living conditions, care needs, and any changes in their behavior or condition that might indicate mistreatment.

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Exhibits The client has started to wake up more, opening her eyes without stimulation and looking around the room. Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.

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Naxlex Comprehensive Predictor Exams

A client presents to the emergency department (ED) reporting abdominal pain. The nurse observes the client's right cheek and eye are bruised and suspects possible domestic violence. Which approach is best for the nurse to use when interviewing the client?

Correct Answer is A

Explanation

Exhibits Which intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.

Correct Answer is ["A","B","D","F","H"]

Explanation

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Exhibits

The client has started to wake up more, opening her eyes without stimulation and looking around the room.

Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.