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 A
Explanation
Choice A rationale
The client’s symptoms of itching, anxiety, a flushed face, and hives after the initiation of a blood transfusion are indicative of an allergic reaction. These symptoms suggest that the client may be having a reaction to the transfused blood, which can occur if the client’s immune system reacts against the blood cells or other components of the transfused blood.
Choice B rationale
While some side effects can occur during a blood transfusion, the symptoms the client is experiencing are not normal side effects of the procedure. Normal side effects might include a slight fever or chills.
Choice C rationale
Although the client is experiencing anxiety, this is likely a symptom of the allergic reaction rather than an indication of an anxiety disorder.
Choice D rationale
Hypersensitivity to the IV gauge material is unlikely to cause the symptoms the client is experiencing. Hypersensitivity reactions to medical device materials are rare and would not typically cause systemic symptoms like itching and hives.
Correct Answer is A
Explanation
Choice A rationale
After drawing up the medication, the nurse should ask another nurse to observe the medication wastage. This is a standard procedure for controlled substances like opioids. The second nurse acts as a witness to ensure that the unused portion of the medication is disposed of properly and not diverted for inappropriate use.
Choice B rationale
Notifying the pharmacy when wasting the medication is not the immediate next step after drawing up the medication. While some institutions may require notification of the pharmacy for controlled substance wastage, the immediate next step is typically to have another nurse witness the wastage.
Choice C rationale
Locking the remaining medication in the controlled substances cabinet is not the immediate next step after drawing up the medication. The remaining medication should be wasted with a witness present.
Choice D rationale
Disposing of the vial with the remaining medication in a sharps container is not the immediate next step after drawing up the medication. The remaining medication should be wasted with a witness present.
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