The nurse recognizes that findings consistent with elder mistreatment.
Short term memory loss.
Malnutrition.
Bilateral leg edema.
Diminished breath sound.
Dark room lighting.
Poor hygiene.
Pressure injuries.
Correct Answer : B,E,F,G
Choice A rationale
Short-term memory loss is not typically associated with elder mistreatment. It may result from normal aging, neurological conditions like Alzheimer's disease, or other medical issues affecting cognitive function. It does not directly indicate mistreatment.
Choice B rationale
Malnutrition in the elderly can be a sign of neglect or mistreatment, where the individual may not receive adequate nutrition due to inadequate caregiving or intentional withholding of food. It can lead to severe health complications and indicates a lack of proper care.
Choice C rationale
Bilateral leg edema can result from various medical conditions, such as heart failure, chronic venous insufficiency, or renal disease. It is not a specific indicator of elder mistreatment and requires a thorough medical evaluation to determine the underlying cause.
Choice D rationale
Diminished breath sounds are typically related to respiratory conditions, such as pneumonia, chronic obstructive pulmonary disease (COPD), or pleural effusion. While they require medical attention, they do not directly indicate elder mistreatment.
Choice E rationale
Dark room lighting can suggest poor living conditions and inadequate care, potentially indicating neglect or mistreatment. Proper lighting is essential for the safety and well-being of elderly individuals, and its absence may reflect a lack of proper care and attention.
Choice F rationale
Poor hygiene is a common sign of neglect in elder mistreatment cases. It indicates that the individual may not receive assistance with personal care, leading to physical and emotional distress. Neglecting hygiene needs can result in infections and other health issues.
Choice G rationale
Pressure injuries, or bedsores, are often a result of prolonged immobility and inadequate repositioning, which can occur in cases of elder mistreatment or neglect. These injuries can lead to severe complications and are indicative of a lack of proper care and attention to the individual's needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice B rationale: Capillary refill time of 6 seconds is significantly delayed and indicates poor peripheral perfusion. This finding suggests that the client may be experiencing decreased cardiac output or hypovolemia, which requires immediate attention to improve circulation and oxygen delivery to tissues.
Choice C rationale: Blood pressure of 90/79 mmHg with a pulse pressure of less than 40 mmHg is a critical finding. The narrow pulse pressure and hypotension indicate potential hypovolemia or shock, which must be addressed urgently to stabilize the client's hemodynamic status.
Choice D rationale: The client’s lack of urine output from the indwelling catheter is concerning and indicates potential kidney dysfunction or decreased renal perfusion. Immediate intervention is necessary to assess and manage potential underlying causes, such as hypovolemia or renal injury.
Choice A rationale: Oxygen saturation of 100% on 40% oxygen is not an immediate concern. While it is important to continue monitoring oxygen levels, the client is currently receiving adequate oxygenation.
Correct Answer is B
Explanation
Choice A rationale
Explaining the ELISA test for confirmation is unnecessary as the client is already confirmed HIV positive. Repeating the test may cause confusion and anxiety without offering additional benefit at this stage.
Choice B rationale
Identifying support systems in the client's life is crucial for addressing the emotional and psychological impact of being HIV positive and a victim of rape. Support systems, such as family, friends, or support groups, can provide the necessary emotional support and practical assistance to help the client cope with the challenges.
Choice C rationale
Inquiring about plans to further education may not be timely or appropriate in the context of the client's current emotional state. The priority should be addressing the client's immediate mental health needs and ensuring they have adequate support systems in place.
Choice D rationale
Exploring feelings of hope for the future is important but may not be the immediate priority. The client is currently experiencing significant emotional distress, so addressing their immediate mental health needs and ensuring support is a higher priority.
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