Which assessment technique provides the most useful data when the nurse is concerned about possible urinary retention?

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.

The laboratory results show a fasting 1-hour glucose screen level of 164 mg/dL and a fasting blood sugar level of 168 mg/dL from a 3-hour oral glucose tolerance test, both of which are above the normal range. Additionally, a two-hour postprandial glucose level of 220 mg/dL is also elevated. These findings suggest the possibility of gestational diabetes mellitus (GDM), a condition of glucose intolerance that arises during pregnancy.

According to the American Diabetes Association, GDM is diagnosed if two or more plasma glucose levels meet or exceed certain thresholds, which include a fasting glucose concentration of 95 mg/dL, a 1-hour glucose concentration of 180 mg/dL, and a 2-hour glucose concentration of 155 mg/dL. The patient's values surpass these thresholds, indicating that further evaluation and management for GDM may be necessary.