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

Perform a thorough physical assessment

Develop a safety plan

Take photographs to document the abuse or neglect

Confront the abuser about concerning actions

he client in front of the suspected abuser

Complete a comprehensive history

Throw away soiled clothing

Answer and Explanation

Correct Answer : A,B,C,F

Choice A rationale
Performing a thorough physical assessment is crucial when elder mistreatment is suspected. It helps to identify any signs of physical abuse or neglect.
Choice B rationale
Developing a safety plan is an important step in ensuring the safety of the elder. This plan can include strategies to avoid potential harm and steps to take if the elder feels unsafe.
Choice C rationale

Taking photographs to document the abuse or neglect can provide concrete evidence of the mistreatment. These photographs can be used in investigations and legal proceedings.
Choice F rationale
Completing a comprehensive history is necessary to understand the full context of the elder’s situation. This includes the elder’s health status, living conditions, and the nature of their relationship with the caregiver.
Choice H rationale
Reporting findings to Adult Protective Services is a critical step in addressing elder mistreatment. Adult Protective Services can conduct further investigations and take necessary actions to protect the elder.

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Correct Answer is A

Explanation

Choice A rationale

Restricted activity can help reduce intestinal activity, thereby decreasing inflammation and allowing for tissue healing within the gastrointestinal tract.
Choice B rationale
While controlling diarrhea episodes is an important aspect of managing Crohn’s disease, it is not the primary purpose of activity restriction.
Choice C rationale
Promoting the healing process is a crucial aspect of managing Crohn’s disease. However, the primary purpose of activity restriction is to reduce intestinal activity, which in turn can promote healing.
Choice D rationale
Decreasing abdominal pain is an important aspect of managing Crohn’s disease, but it is not the primary purpose of activity restriction.

A. One positive response indicates the patient should seek help with alcohol addiction. B. All responses to the CAGE Questionnaire must be positive to suggest alcohol dependence. C. The CAGE Questionnaire is a tool used to identify general substance abuse. D. At least two positive responses are strongly suggestive of alcohol dependence.

Correct Answer is D

Explanation

Choice A rationale
While any positive response on the CAGE questionnaire could be a cause for concern and warrant further investigation, one positive response does not definitively indicate that the patient should seek help with alcohol addiction. The CAGE questionnaire is a screening tool used to identify potential problems with alcohol, but it is not diagnostic. A healthcare provider would need to conduct a more thorough assessment to diagnose alcohol addiction.
Choice B rationale
It is not necessary for all responses to the CAGE questionnaire to be positive in order to suggest alcohol dependence. The CAGE questionnaire is a screening tool, and while a greater number of positive responses increases the likelihood of alcohol dependence, it is not a requirement for all responses to be positive. A score of two or more is considered clinically significant.

Choice C rationale
The CAGE questionnaire is indeed a tool used to identify potential problems with alcohol, but it is not used to identify general substance abuse. The CAGE questionnaire specifically asks about feelings related to alcohol use. There are other screening tools available that are designed to identify issues with other substances.
Choice D rationale
This is the correct answer. The CAGE questionnaire is a validated screening tool that is widely used in clinical settings to detect alcoholism. It is considered positive, and suggestive of alcohol dependence, if two or more questions are answered affirmatively.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Restricted activity is prescribed for a client with Crohn’s disease. What is the primary purpose of the activity restriction?

Correct Answer is A

Explanation

The patient provides three positive responses to items on the CAGE (Cut down, Annoyed, Guilty, Eye-opener) query. What interpretation should the nurse provide to the patient?

Correct Answer is D

Explanation

A nurse in the emergency department is collecting evidence for a rape kit from a woman who reports that she was raped while returning to her dormitory from the university library. Which intervention is most crucial for the nurse to implement?

The nurse uses the Modified Caregiver Strain Index (MCSI) and determines that the daughter is under significant stress caused by the assumption of her mother’s care.

The nurse is about to administer a histamine 2-receptor antagonist to a patient with peptic ulcer disease. What is the primary purpose of this class of medication?

A caregiver brings a client with end-stage Alzheimer’s disease to the clinic for an appointment with the healthcare provider. The caregiver confides in the nurse about experiencing sleepless nights and frequent bouts of crying. What action should the nurse take?

A client on the mental health unit has been displaying signs of agitation, such as scowling and pacing rapidly up and down the hallway for several minutes. Which behaviors should the nurse prioritize for monitoring?

A client with chronic kidney disease (CKD) has elevated blood urea nitrogen (BUN) and serum creatinine levels. The client reports feeling fatigued and is unable to concentrate during the morning assessments. What action should the nurse take based on these findings?