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Exhibits

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

Report findings to Adult Protective Services.

Perform a thorough physical assessment.

Confront the abuser about concerning actions.

Develop a safety plan.

Question the client in front of the suspected abuser.

Take photographs to document the abuse or neglect.

Throw away soiled clothing.

Complete a comprehensive history.

Answer and Explanation

Correct Answer : A,B,D,F,H

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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Correct Answer is B

Explanation

A. Sodium intake with meals and snacks affects the blood pressure. While sodium can contribute to blood pressure increases, the primary reason for monitoring blood pressure in this case is to detect the kidney-related hypertension.

B. Elevated blood pressure must be anticipated and identified quickly. Blood pressure can increase significantly in acute glomerulonephritis due to fluid retention and kidney impairment. Frequent monitoring helps to identify and treat elevated blood pressure early, preventing complications.

C. Blood pressure fluctuations mean that the condition has become chronic. Acute glomerulonephritis typically causes fluctuating blood pressure, but this does not necessarily indicate chronic disease.

D. Hypotension leading to sudden shock can develop at any time. Hypotension is less common in acute glomerulonephritis compared to hypertension, making this response less accurate.

Correct Answer is []

Explanation

Potential Condition - Tension pneumothorax:

The client presents with sudden decreased oxygen saturation (56%) after being intubated, along with absent breath sounds on the left side and a tracheal deviation to the right. These are classic signs of a tension pneumothorax, which occurs when air enters the pleural space and is trapped, leading to increased pressure on the lung and mediastinum, resulting in tracheal deviation and respiratory compromise. The low PaO2 and high PaCO2 in the ABG further support the diagnosis of respiratory failure due to this condition.

Actions to Take:

Collect equipment for a needle aspiration: Tension pneumothorax is treated emergently by needle decompression to release the trapped air and relieve the pressure on the lung and heart. The nurse should prepare for this procedure by gathering the necessary equipment.

Increase the fraction of inspired oxygen on the ventilator: Increasing the oxygen delivery can help improve the client's oxygenation while preparing for further intervention, such as needle aspiration.

Parameters to Monitor:

Blood gas: The ABG results show acid-base imbalance (low pH, elevated PaCO2, low PaO2), which need continuous monitoring to assess the effectiveness of interventions, such as needle decompression and oxygenation support.

Breath sounds: The nurse should continue auscultating for changes in breath sounds as the tension pneumothorax is treated. The resolution of the absent breath sounds on the left side would indicate the success of the intervention.

Rationale for incorrect choices:

Endotracheal tube obstruction: The absence of breath sounds on one side and the tracheal deviation suggest a pneumothorax, not an obstruction. Obstruction would typically cause wheezing or decreased breath sounds on both sides, but it wouldn’t cause tracheal deviation.

Pulmonary hypertension: Pulmonary hypertension might cause hypoxia and respiratory distress, but it would not cause the sudden and severe signs of a tension pneumothorax, such as tracheal deviation and unilateral absent breath sounds

Ventilator malfunction: While a ventilator malfunction could affect oxygenation, it would not cause the physical signs of tension pneumothorax (tracheal deviation and absent breath sounds on one side). A malfunction would likely affect the entire chest and wouldn’t cause localized changes as seen in this client.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?

Correct Answer is B

Explanation

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

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Exhibits

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