A client received a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, which action should the nurse implement?

Rationale for Correct Choices

• Neglect: The client presents with signs of poor hygiene, untreated pressure injuries, confinement to bed without a clear medical reason, and a reduction in social interaction and autonomy. These factors collectively indicate neglect, which is the failure of a caregiver to meet the basic physical, emotional, and social needs of a dependent adult.
• Adult Protective Services: Adult Protective Services is the appropriate authority to report suspected abuse or neglect of older adults living in private homes. As a mandated reporter, the nurse is legally required to report suspected elder mistreatment to APS to initiate an investigation and protect the client.

Rationale for Incorrect Choices

• Sexual abuse: There are no indicators such as bruising in private areas, fear of the caregiver, or behavioral cues that might suggest sexual trauma. The case centers on physical neglect, not sexual abuse.
• Financial exploitation: The client has not reported any unauthorized financial activity, and there is no evidence of the caregiver misusing or controlling the client’s finances. This makes financial exploitation an unlikely concern.
• Long Term Care Program: This agency oversees long-term care facilities like nursing homes. Since the client resides in a private home, the situation falls outside the jurisdiction of this program.
• State Department of Health: The Department of Health primarily monitors healthcare providers and facilities, not private caregiving situations. Therefore, it is not the correct agency to report suspected elder abuse in this context.

Rationale:

A. Lentils: Lentils are high in fiber and are not part of a full liquid diet because they require chewing and contain residue. They are appropriate for a soft or regular diet, not a full liquid one.

B. Tea: Tea is a clear liquid and is included in a full liquid diet. It requires no chewing and leaves no residue, making it suitable postoperatively.

C. Whole grain breads: Breads are solid foods and not permitted on a full liquid diet. They require chewing and do not meet the consistency guidelines for this diet type.

D. Potato soup: Smooth, blended soups like potato soup are appropriate for a full liquid diet as long as there are no chunks. They provide calories and are easy to swallow.

E. Cheese: Cheese is a solid food and is not permitted on a full liquid diet.