A client's adult child left the facility to go home and get the client's prescribed medications.
The client is visibly more relaxed and now speaking more openly to staff with improved eye contact.
The client reports they have lived with their adult child for the past several months due to their inability to care for themselves without assistance.
The client states their adult child "gets frustrated with me, but I understand why.
I move so slow and need help with everything.”. The client states they give their retirement income to their adult child to pay for their prescribed medication and household expenses, but they have no access to the bank account.
The client states their adult child makes "a few meals a week" and that there is little food in the house.
What should be the nurse's priority action based on this information?
Report suspected elder abuse to the appropriate authorities.
Ask the client's adult child about the client's financial situation.
Educate the client's adult child about the importance of nutrition.
Encourage the client to discuss their frustrations with their adult child.
The Correct Answer is A
Choice A rationale
Based on the client's statements, there is strong evidence of neglect and potential exploitation. Neglect is indicated by the inadequate food supply and minimal meal preparation. Financial exploitation is suggested by the client's lack of access to their retirement income, despite it being used for their care. This situation poses a serious risk to the client's well-being, triggering the nurse's ethical and legal duty to report suspected elder abuse to the appropriate authorities.
Choice B rationale
While gathering more information is often a good practice, directly questioning the adult child about financial matters could escalate the situation and potentially put the client at further risk. The primary responsibility of the nurse in this scenario is to ensure the client's safety, and the existing information is sufficient to warrant a report. The client has already provided a detailed account of the financial arrangement and their lack of access to funds, which is a key indicator of exploitation.
Choice C rationale
Educating the adult child about nutrition, while potentially helpful in some circumstances, does not address the immediate and serious issues of neglect and financial exploitation. The client's safety is the priority. Focusing solely on education ignores the broader pattern of abuse and the client's vulnerability, which requires a more direct and protective intervention.
Choice D rationale
Encouraging the client to speak with their adult child may place them in a more vulnerable position and could increase the risk of retaliation or further neglect. The client has already expressed an understanding of their adult child's frustration, and this approach fails to address the power imbalance and exploitative nature of the relationship. It is not an appropriate or safe intervention in a situation of suspected abuse. *.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
For a preschooler, play is the primary mechanism for coping and learning. A pounding board allows the child to express frustration and aggression in a safe, appropriate manner. This type of play helps to relieve tension and anxiety associated with hospitalization. It provides a healthy outlet for emotions that the child may not be able to articulate verbally, which is crucial for this developmental stage.
Choice B rationale
Preschoolers have a limited understanding of complex language. Using medical terminology can be frightening and confusing to them, increasing their anxiety. Nurses should use simple, concrete language that the child can understand, such as "checking your arm" instead of "taking your blood pressure," to help them feel more secure and cooperative with care.
Choice C rationale
Preschoolers thrive on routine and predictability. Establishing a new routine can be disruptive and increase their stress and fear. The nurse should strive to maintain as much of the child's home routine as possible to provide a sense of security and normalcy. This helps them feel more in control and less overwhelmed by the hospital environment.
Choice D rationale
A preschooler may experience separation anxiety when a parent leaves the room. Performing assessments while the parent is present helps the child feel more secure and supported. The parent can also provide comfort and help distract the child, which can make procedures easier and less frightening for the child. This promotes a trusting relationship between the child, parent, and nurse.
Correct Answer is A
Explanation
Choice A rationale
Informed consent is a dynamic and ongoing process, not a one-time event. A client has the autonomous right to refuse a procedure at any point, even after having previously signed a consent form. This right is based on the principle of client autonomy, which states that competent individuals have the right to make decisions about their own healthcare, including the right to withdraw consent at any time. The signed form simply documents that the discussion occurred; it does not nullify the client's right to change their mind.
Choice B rationale
The ability to write is not a prerequisite for providing informed consent. A client who is unable to write can still provide verbal consent, and this is typically documented by a witness. The key components of informed consent are the client's understanding of the procedure and their voluntary agreement. As long as the client can comprehend the information and communicate their decision, they are considered capable of providing consent. A mark or a signature from a witnessed verbal consent can be used to formalize the documentation process.
Choice C rationale
A client who is blind is fully capable of providing informed consent as long as they can understand the information being presented. The nurse or healthcare provider must ensure that the information is communicated in a manner the client can comprehend, which may include reading the consent form aloud and answering any questions. The visual impairment does not compromise the client's cognitive ability to make decisions about their own healthcare, and therefore, a guardian is not required for this reason.
Choice D rationale
While a nurse can and often does clarify information, the primary responsibility for explaining surgical risks and benefits to a client lies with the surgeon or the healthcare provider performing the procedure. The physician must provide a comprehensive explanation of the procedure, including all potential risks, benefits, and alternatives, to ensure the client is fully informed. The nurse's role is to act as a witness to the signature and to ensure the client has had their questions answered, and to notify the provider if they have new questions or concerns. *.
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