Exhibits
Which intervention(s) should the practical nurse (PN) initiate if elder mistreatment is suspected? Select all that apply.
Throw away soiled clothing.
Report findings to Adult Protective Services.
Complete a comprehensive history.
Perform a thorough physical assessment.
Question the client in front of the suspected abuser.
Develop a safety plan.
Take photographs to document the abuse or neglect.
Confront the abuser about concerning actions.
Correct Answer : B,C,D,F,G
A. Throw away soiled clothing.
Not Applicable
Throwing away soiled clothing does not address the issue of elder mistreatment and may not be relevant to the investigation of abuse or neglect. Instead, the focus should be on assessing the situation, documenting evidence, and ensuring the client’s safety. The PN’s role includes observing signs of mistreatment and reporting them, not managing personal items.
B. Report findings to Adult Protective Services.
Applicable
Reporting to Adult Protective Services is crucial for initiating a formal investigation into suspected elder mistreatment. These agencies are equipped to handle allegations of abuse and neglect through professional investigation and intervention. This step ensures that the client receives the appropriate protection and that any mistreatment is addressed legally.
C. Complete a comprehensive history.
Applicable
A comprehensive history helps the PN understand the client’s background, current living conditions, and any potential patterns of mistreatment. This information is essential for identifying signs of abuse or neglect and for making an informed report to the appropriate authorities. It also assists in documenting the client’s experiences and concerns.
D. Perform a thorough physical assessment.
Applicable
A thorough physical assessment allows the PN to identify and document signs of physical abuse or neglect, such as injuries or unsanitary conditions. This documentation is important for supporting the findings in the report to Adult Protective Services and for planning further interventions. The assessment provides evidence of mistreatment and helps in evaluating the client’s overall well-being.
E. Question the client in front of the suspected abuser.
Not Applicable
Questioning the client in front of the suspected abuser can be unsafe and may lead to further mistreatment of the client. It is important to conduct these discussions privately to protect the client and obtain accurate information. The PN should gather information discreetly and report findings to the authorities without risking the client’s safety.
F. Develop a safety plan.
Applicable
Developing a safety plan is essential for ensuring the client’s immediate safety and preparing for any potential risks of mistreatment. This plan addresses how the client can be protected from further harm and outlines steps for seeking help if needed. It is a proactive measure to safeguard the client’s well-being.
G. Take photographs to document the abuse or neglect.
Applicable
Photographs serve as objective evidence of abuse or neglect, which is valuable for investigations by Adult Protective Services. Documenting visual evidence helps in assessing the severity of the mistreatment and supports the report made to authorities. It provides a clear record of conditions that might otherwise be subjective or difficult to convey.
H. Confront the abuser about concerning actions.
Not Applicable
Confronting the abuser can escalate the situation and put the client at further risk of mistreatment. This action should be handled by professionals trained to manage such situations. The PN’s role is to observe, document, and report findings rather than directly addressing the suspected abuser
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
Response 1
A. Fluid volume deficit
The client has signs of dehydration such as dry mucous membranes and a recent history of not having much to eat or drink in the past 2 days, which indicates a fluid volume deficit.
B. Respiratory alkalosis
There is no evidence to support respiratory alkalosis. The client's primary issues are related to infection and dehydration.
C. Hypoxia
The client’s oxygen saturation is 100% on 2 L/minute nasal cannula, so hypoxia is not a current issue.
D. Diarrhea
Diarrhea is not mentioned in the history, symptoms, or findings. It is not relevant to the client's condition.
Response 2
A. Decreased fluid intake
The client has not had much to eat or drink in the past 2 days, contributing directly to the fluid volume deficit.
B. Increased respiratory rate
While the client has an increased respiratory rate, it is a symptom of pneumonia rather than a cause of fluid volume deficit.
C. Infection
Although the client has pneumonia, the fluid volume deficit is more directly related to decreased fluid intake than to infection.
D. Heart disease
Heart disease is not mentioned and is not relevant to the client’s current presentation.
Correct Answer is ["A","D","E"]
Explanation
A. Place the drink where the client can reach from her bed
Placing the drink where the client can easily reach it encourages regular fluid intake. Accessibility is key for clients who may be feeling weak or fatigued, especially when dealing with symptoms of illness like fever and cough. Ensuring that fluids are within reach minimizes barriers to drinking and supports better hydration efforts.
B. Encourage drinks with high sugar content
Drinks with high sugar content are not ideal for promoting adequate fluid intake. High sugar content can worsen symptoms like nausea or dehydration and may lead to increased thirst or gastrointestinal upset, which is counterproductive to encouraging fluid intake. Offering fluids with balanced electrolytes and moderate sugar content is more beneficial.
C. Only offer water or other clear drink
Offering only water or clear drinks can be too restrictive and may not meet the client's preferences or needs. While clear liquids are appropriate, incorporating a variety of fluids can improve hydration and patient satisfaction. It is beneficial to offer options that the client might find appealing.
D. Ask the client what her favorite drink is
Asking the client for her favorite drink engages her in the decision-making process and increases the likelihood of her consuming more fluids. Personal preferences can significantly affect fluid intake, and offering drinks she likes can help in achieving adequate hydration.
E. Offer both hot and cold drinks
Offering both hot and cold drinks can cater to the client’s preferences and provide comfort, which may encourage her to drink more fluids. Variety in temperature can make drinking fluids more appealing, especially if the client is feeling unwell or has specific preferences.
F. Suggest popular drinks like coffee or soda
Suggesting coffee or soda is not recommended due to their diuretic effects and potential for dehydration. Coffee and soda can also interfere with electrolyte balance and are generally not suitable for hydration in a clinical setting where the goal is to address fluid volume deficit
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