Scenario
A nurse is conducting an initial home health assessment for an 84-year-old female client in her daughter’s home. The client was recently discharged after hospitalization for an exacerbation of heart failure (HF).
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Rationale for correct answers
Neglect: The client’s condition and living situation indicate neglect. The client is frail, has poor hygiene, unkempt hair, dry skin, and visible pressure injuries. The daughter, who is the primary caregiver, admits to being overwhelmed and neglecting the client’s needs, such as hygiene and repositioning. Neglect is defined as the failure to provide necessary care, assistance, and supervision to a dependent individual, leading to harm or potential harm.
Adult Protective Services: As a mandated reporter, the nurse must report the signs of elder mistreatment to Adult Protective Services (APS). APS is responsible for investigating reports of abuse, neglect, and exploitation of elderly or disabled adults. Reporting to APS ensures that the client receives the necessary intervention and support to address the neglect and improve her quality of life.
Rationale for incorrect answers
Abandonment: Abandonment refers to deserting an elderly person, leaving them without the necessary care and support. In this case, the client has not been deserted; her daughter is present and attempting to provide care, although she is overwhelmed and neglectful. Therefore, abandonment is not the correct answer.
Physical abuse: Physical abuse involves the intentional use of physical force that results in bodily injury, pain, or impairment. There is no evidence of physical abuse in this case. The client’s condition is due to neglect, not physical harm inflicted by another person.
Self-neglect: Self-neglect occurs when an individual fails to meet their own basic needs, such as personal hygiene, nutrition, or medical care. In this scenario, the client is dependent on her daughter for care and unable to provide for herself due to limited mobility. The neglect is not self-imposed but rather due to the caregiver's inability to meet her needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Participation of community leaders in planning the program is crucial because these leaders have an in-depth understanding of the community's needs and concerns. Their involvement ensures that the program is culturally relevant and addresses the specific health disparities faced by African-American women. Additionally, community leaders can help foster trust and encourage participation from community members, making the program more effective.
Choice B rationale
While morbidity data for breast cancer in women of all races can provide valuable information on overall trends, it does not address the specific needs and challenges faced by African-American women. Focusing on the unique risks and barriers faced by this group is essential for designing an effective health promotion program.
Choice C rationale
A listing of African-American women who live in the community is useful for outreach and engagement but does not provide the essential insight needed to design a culturally sensitive and relevant program. Participation from community leaders is more effective in understanding and addressing the community's specific needs.
Choice D rationale
Technical assistance to produce a video on breast self-examination is valuable for education but is not the most important resource for designing a comprehensive health promotion program. The program must be tailored to the community's unique needs, which requires input from community leaders.
Correct Answer is A
Explanation
Choice A rationale
The scenario indicates that the client's contractions are increasing in frequency and intensity, and she reports significant pain, prompting a request for an epidural. The cervical exam shows she is 5 cm dilated and 90% effaced, with the baby at 0 station, which is typical for the active phase of labor. This is the appropriate time for an epidural, as pain management is often needed when contractions become more intense and dilation progresses. Clear amniotic fluid after artificial rupture of membranes also suggests no immediate complications.
Choice B rationale
Immediate cesarean section is generally reserved for situations of fetal distress or other obstetric emergencies. There is no mention of fetal heart rate abnormalities or other signs of distress in the scenario. While MS can complicate pregnancy, it does not automatically necessitate a cesarean section without specific indications. The decision for cesarean should be based on maternal or fetal indications not present in this case.
Choice C rationale
The instruction to start pushing is only appropriate during the second stage of labor when the cervix is fully dilated (10 cm). The client is 5 cm dilated, indicating she is still in the active phase of the first stage of labor. Encouraging pushing at this stage would be premature and could cause unnecessary exhaustion and potential harm to the cervix and fetus. Pushing is typically reserved for the final stage when the baby's head is crowning.
Choice D rationale
Administering an epidural and experiencing immediate pain relief aligns with the standard protocol for labor analgesia when requested by the client. Epidural anesthesia is a common and effective method for pain management during labor. This option respects the client's expressed need for pain relief and involves the healthcare provider in safely administering the epidural. Immediate relief from pain can help the client focus on labor progression and reduce stress.
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