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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["8"]
Explanation
Step 1 is: Calculate the total units of heparin in the bag, which is 25,000 units.
Step 2 is: Divide the total units by the total volume to find the units per mL, which is (25,000 units ÷ 250 mL) = 100 units/mL.
Step 3 is: Divide the desired units per hour by the units per mL to find the mL/hr, which is (800 units/hr ÷ 100 units/mL) = 8 mL/hr. So, the infusion pump rate should be set at 8 mL/hr.
Correct Answer is D
Explanation
Choice A rationale
While elevating the head of the bed to 30 degrees can be helpful in some procedures, it is not the most crucial step when inserting a nasogastric (NG) tube. The primary goal is to ensure the tube enters the esophagus and not the trachea.
Choice B rationale
If a patient begins to gag or choke during the procedure, it may indicate that the tube has entered the trachea instead of the esophagus. However, removing the NG tube immediately might not always be the best course of action. It’s important to first assess the situation, reposition the patient, and attempt to advance the tube while the patient swallows.
Choice C rationale
Applying suction to the NG tube prior to insertion is not a standard practice. Suction is typically applied after the NG tube has been properly placed and secured, to remove gastric contents for therapeutic (decompression) or diagnostic (analysis) purposes.
Choice D rationale
Encouraging the patient to take sips of water can facilitate the insertion of the NG tube into the esophagus. Swallowing helps guide the tube down into the esophagus instead of the trachea.
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