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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Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale

Inserting the catheter at a 45-degree angle is not recommended for an older adult client with fragile skin. A lower angle of insertion is usually more appropriate.

Choice B rationale

Positioning the client’s arm in a dependent position can help engorge the veins, making it easier to insert the IV catheter.

Choice C rationale

Removing excess hair from the insertion site is not the first action the nurse should take. While it’s important to have a clean and clear insertion site, positioning the client’s arm correctly is a more immediate concern.

Choice D rationale

Initiating IV therapy in the veins of the hand is not the first action the nurse should take. While the veins of the hand can be used for IV insertion, positioning the client’s arm correctly is a more immediate concern.

A. Touch the patient’s face with a cotton ball. B. Apply a vibrating tuning fork to the patient’s forehead. C. Have the patient stand with their arms at their sides and their feet together. D. Perform direct percussion over the area of the kidneys.

Correct Answer is C

Explanation

Choice A rationale

Touching the patient’s face with a cotton ball is not part of the Romberg test. This action is more commonly associated with tests of facial sensation.

Choice B rationale

Applying a vibrating tuning fork to the patient’s forehead is not part of the Romberg test. This action is more commonly associated with tests of vibratory sensation.

Choice C rationale

Having the patient stand with their arms at their sides and their feet together is the correct method for conducting a Romberg test.

Choice D rationale

Performing direct percussion over the area of the kidneys is not part of the Romberg test. This action is more commonly associated with tests of kidney function or the presence of kidney disease.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to insert a peripheral IV catheter for an older adult client. Which action should the nurse plan to take?

Correct Answer is B

Explanation

A nurse is conducting a Romberg test as part of a patient’s physical assessment. Which of the following methods should the nurse employ?

Correct Answer is C

Explanation

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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?