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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. "This must be very frightening for you. Let's talk more about it.": This response demonstrates empathy and validation of the client's feelings, which can help build trust. It acknowledges the client's emotional state while not challenging or confronting their delusion directly. This approach helps maintain rapport while encouraging the client to express themselves.

B. "What makes you think the staff is following you?": This response could be perceived as questioning the validity of the client's experience, which may feel confrontational or invalidating. It is not the best approach for engaging a client with paranoid delusions.

C. “Why do you feel the staff is the FBI?": This question could also challenge the client's delusion and inadvertently reinforce their sense of being persecuted. Asking such a question might escalate anxiety rather than calm the client.

D. "The psychiatric staff is not FBI. They are here to help you.": While this response is factually correct, it may be perceived as dismissive of the client's experience. Confronting the delusion directly is generally not helpful and can increase the client's feelings of mistrust.

A. Place a pillow under the child's head. B. Turn the child onto their back. C. Place a padded tongue blade in the child's mouth. D. Restrain the child's upper extremities.

Correct Answer is A

Explanation

A. Place a pillow under the child's head: This is correct. The nurse should place a soft object, such as a pillow or folded blanket, under the child’s head to prevent head injury during a seizure. It is important to protect the patient from harm without interfering with the seizure.

B. Turn the child onto their back: This is not advisable during a seizure. The child should remain in a safe position, preferably on their side to help maintain the airway and prevent aspiration. Turning onto their back is not a first-line intervention.

C. Place a padded tongue blade in the child's mouth: This is incorrect. A padded tongue blade should never be inserted into the mouth during a seizure, as it can cause dental or oral injury, and may lead to aspiration or choking.

D. Restrain the child's upper extremities: Restraining the child is not recommended during a seizure. The child should not be physically restrained during the event, as this could cause injury or increase the risk of aspiration. The nurse should focus on providing safety and not interfering with the natural movements during a seizure.

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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?

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