A nurse in an emergency department is caring for a client. Nurses' Notes.

1200:.

Client is an 82-year-old male who presents with his adult child for evaluation of right arm pain after a fall. Client noted to have several superficial abrasions on right forearm and elbow. Also has numerous bruises in various stages of healing on arms and upper chest. Client rates pain in right lower forearm an 8 on a 0 to 10 pain scale and is not moving the arm.

1210:.

Client noted to keep head down and makes limited eye contact. Speaks very softly and looks at adult child before answering interview questions. Has strong body odor and clothes are unclean. Client's adult child answers most questions. Client grimacing and guarding right arm.

Client weighed, is 56.2 kg (124 lb) and 175 cm (69 in) tall. BMI 18.3.

1230:.

Client's adult child left facility to go home and get the client’s prescribed medications. Client visibly more relaxed and now speaking more openly to staff with improved eye contact. Client reports that he has lived with his adult child for the past several.

Vital Signs. 1200:.

Temperature 36.7° C (98° F). Heart rate 96/min.

Blood pressure 142/96 mm Hg. Respiratory rate 16/min.

SpO2 97% on room air.

The nurse is preparing to speak to the facility's Social Worker about the client's condition.

Select the 5 findings the nurse should plan to include in the report.

Answer is B, C, D, E, F. These are the findings that suggest possible elder abuse or neglect.

• B: Client’s report of lack of food in home. This may indicate neglect by the adult child who is supposed to provide adequate nutrition for the client.
• C: Client’s report of lack of access to bank accounts. This may indicate financial abuse by the adult child who is controlling the client’s money without his permission.
• D: Client’s avoidance of eye contact. This may indicate emotional abuse by the adult child who is intimidating or threatening the client.
• E: Client’s report of weight loss. This may indicate neglect by the adult child who is not meeting the client’s basic needs or physical abuse by the adult child who is causing bodily harm to the client.
• F: Numerous bruises in various stages of healing. This may indicate physical abuse by the adult child who is hitting or injuring the client.

A: ECG results. This is not a finding that suggests elder abuse or neglect. It is a diagnostic test that measures the electrical activity of the heart and can help detect cardiac problems. It does not provide information about the client’s social or emotional well-being.

Normal ranges for vital signs:.

• Temperature: 36.1°C to 37.2°C (97°F to 99°F).
• Heart rate: 60 to 100 beats per minute.
• Blood pressure: less than 120/80 mm Hg.
• Respiratory rate: 12 to 20 breaths per minute.
• SpO2: 95% to 100% on room air. Table for BMI categories:

The client’s BMI is 18.3, which indicates he is underweight and may be malnourished or have a medical condition that causes weight loss.

The correct answer is choice C. A client who was just given a glass of orange juice for a low blood glucose level.

This client should be assessed first because they are at risk of hypoglycemia, which is a medical emergency that can cause seizures, coma, or death if not treated promptly.

The nurse should check the client’s blood glucose level again and provide additional carbohydrates or glucose if needed.

Choice A is wrong because a client who is scheduled for a procedure in 1 hr is not in immediate danger and can be assessed later.

The nurse should verify the client’s consent, allergies, and vital signs before the procedure, but this is not a priority over a client with low blood glucose.

Choice B is wrong because a client who received a pain medication 30 min ago for postoperative pain is likely to have improved pain relief and does not need immediate assessment.

The nurse should monitor the client’s pain level, vital signs, and respiratory status periodically, but this is not a priority over a client with low blood glucose.

Choice D is wrong because a client who has 100 mL of fluid remaining in his IV bag is not in immediate danger and can be assessed later.

The nurse should change the IV bag when it is empty or nearly empty, but this is not a priority over a client with low blood glucose.

Normal blood glucose levels are between 70 to 100 mg/dL (3.9 to 5.5 mmol/L) when fasting, and less than 140 mg/dL (7.8 mmol/L) two hours after eating. A blood glucose level below 70 mg/dL (3.9 mmol/L) is considered hypoglycemia and requires immediate treatment. Orange juice is a source of simple carbohydrates that can raise blood glucose quickly, but it may not be enough to prevent hypoglycemia in some cases.