A home health nurse is caring for an older adult client who lives with a family caregiver and has urinary incontinence. The client states, "I guess I will be locked in my room again for wetting the bed." Which of the following actions should the nurse take?
Contact the client's caregiver to discuss the client's comment.
Review the medical record to see if the client has reported abuse in the past.
Report the suspected abuse to the nurse manager.
Restrict family members from visiting with the client.
The Correct Answer is B
A. Contacting the client's caregiver to discuss the client's comment might be helpful in some situations, but the priority in this scenario is to assess the possibility of abuse or mistreatment, not to confront the caregiver immediately.
B. Reviewing the medical record to see if the client has reported abuse in the past is correct. The nurse should first gather relevant information to understand the context of the client's statement. If the client has a history of reporting abuse or signs of mistreatment, it may provide critical insight.
C. Reporting suspected abuse to the nurse manager could be necessary if abuse is confirmed, but it is important to first assess the situation and gather information before making such a report.
D. Restricting family members from visiting with the client is an extreme response without any evidence of abuse. The nurse should assess the situation further before taking such action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Elevated blood pressure: Diabetic ketoacidosis (DKA. typically does not cause elevated blood pressure. In fact, due to dehydration from increased urination, clients often present with hypotension or normal blood pressure, rather than hypertension.
B. Bounding pulse: A bounding pulse is not commonly associated with DKA. It may be seen with conditions such as fever or sepsis, but DKA is more likely to cause a weak or thready pulse due to fluid volume deficit and dehydration.
C. Fruity breath odor: A fruity or acetone-like breath odor is a hallmark sign of diabetic ketoacidosis. This is caused by the presence of ketones in the blood, which are produced as the body breaks down fat for energy when glucose is unavailable.
D. Clammy skin: Clammy skin is more likely to be associated with hypoglycemia, not DKA. In DKA, the skin is typically dry due to dehydration, and the client may appear flushed, not clammy.
Correct Answer is D
Explanation
A. Encouraging the toddler to flush the toilet while still seated is incorrect. Some children may be startled by the flushing sound, which can create fear and resistance to toilet training. It is better to allow the child to stand before flushing if they show hesitation.
B. Having the toddler remain on the toilet for a minimum of 20 minutes is incorrect. Extended sitting can lead to discomfort and frustration, making the experience negative. Shorter, 5- to 10-minute sessions are more effective and developmentally appropriate.
C. Waking the toddler every 2 hours in the night to prevent bed-wetting is incorrect. Nighttime bladder control develops gradually, and disrupting sleep can be counterproductive. Instead, using protective bedding and encouraging toileting before bedtime is recommended.
D. Giving the toddler a sticker after each successful toileting attempt is correct. Positive reinforcement, such as stickers or praise, encourages consistency and motivation, which is particularly beneficial for children with cognitive impairments.
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