A home health nurse is conducting an admission assessment of an elderly patient who has their caregiver present.

Which observation should the nurse identify as a potential sign of elder abuse?

The patient is in a wheelchair with the wheels locked.

The patient reports receiving a full bath twice each week.

The caregiver insists on staying in the room.

The caregiver is the patient’s financial power of attorney.

Answer and Explanation

The Correct Answer is C

Choice A rationale

A patient being in a wheelchair with the wheels locked does not necessarily indicate elder abuse. It could simply mean that the patient has mobility issues and the wheelchair is a means of transportation for them. The wheels being locked could be a safety measure to prevent the wheelchair from moving unexpectedly.

Choice B rationale

The patient reporting receiving a full bath twice each week does not indicate elder abuse. In fact, it shows that the patient’s hygiene needs are being met regularly. Regular bathing is part of good personal hygiene and is important for overall health.

Choice C rationale

The caregiver insisting on staying in the room during the nurse’s assessment could be a potential sign of elder abuse. This could indicate that the caregiver is controlling or overbearing, and may be trying to monitor or control the patient’s interactions with others. It could also suggest that the caregiver is trying to hide something or prevent the patient from speaking freely.

Choice D rationale

The caregiver being the patient’s financial power of attorney does not necessarily indicate elder abuse. A financial power of attorney is a legal document that gives someone the authority to handle financial transactions on behalf of another person. It is often used when a person is unable to manage their own financial affairs due to illness or incapacity.

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Correct Answer is D

Explanation

Choice A rationale

While showering frequency can vary depending on the specific isolation precautions, it does not indicate understanding of the protective isolation precautions.

Choice B rationale

Informing friends and family to visit when feeling well does not indicate understanding of protective isolation precautions. Protective isolation precautions are designed to protect the patient from infections, not based on how the patient is feeling.

Choice C rationale

Taking a plane to visit grandchildren does not indicate understanding of protective isolation precautions. Travel restrictions would depend on the specific condition and doctor’s advice.

Choice D rationale

Wearing a face mask when leaving the hospital room is a common requirement in protective isolation precautions to prevent the spread of infections.

A. Determine the reasons why the client is refusing to use the incentive spirometer. B. Document the client’s refusal to participate in health restorative activities. C. Administer a pain medication to the client.

Correct Answer is A

Explanation

The nurse’s priority action should be to determine the reasons why the client is refusing to use the incentive spirometer. Understanding the client’s concerns or fears can help the nurse address them and encourage the client to participate in this important aspect of postoperative care.

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A home health nurse is conducting an admission assessment of an elderly patient who has their caregiver present. Which observation should the nurse identify as a potential sign of elder abuse?

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A home health nurse is conducting an admission assessment of an elderly patient who has their caregiver present.

Which observation should the nurse identify as a potential sign of elder abuse?