A nurse is admitting an older adult client who is transferring from another facility.
The nurse notes pressure ulcers on the client's coccyx and abrasions around both wrists.
Which of the following actions should the nurse take to address suspicions of elder abuse?
Contact the family regarding the client's condition.
Notify risk management.
Inform the transferring agency of the client's condition.
Privately interview the client about the injuries.
The Correct Answer is D
The correct answer is choice d. Privately interview the client about the injuries.
Choice A rationale:
Contacting the family regarding the client’s condition might not be appropriate if the family is suspected of being involved in the abuse. It could potentially put the client at further risk.
Choice B rationale:
Notifying risk management is important for documentation and internal review, but it does not directly address the immediate need to assess and ensure the client’s safety.
Choice C rationale:
Informing the transferring agency of the client’s condition is necessary for continuity of care, but it does not address the immediate need to investigate the cause of the injuries and ensure the client’s safety.
Choice D rationale:
Privately interviewing the client about the injuries allows the nurse to gather more information about the cause of the injuries in a safe and confidential manner. This step is crucial in assessing the situation and determining if further action, such as reporting to authorities, is needed. It ensures the client’s safety and helps in identifying any potential abuse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Applying skin sealant on damp skin is not a correct technique when changing an ostomy appliance. Skin should be clean and thoroughly dry before applying any ostomy products. Moisture on the skin can interfere with the adhesion of the pouching system, leading to skin irritation and leakage.
Choice B rationale:
Removing the appliance before emptying the pouch is not the correct technique. Ostomy pouches are designed to be emptied without removing the entire appliance. Removing the pouch unnecessarily can cause discomfort to the client and may damage the surrounding skin. Regular emptying of the pouch while leaving the appliance in place is the appropriate practice.
Choice C rationale:
Ensuring that the skin is slightly damp for better adhesion of the pouch is not accurate. Ostomy pouches adhere best to clean, dry skin. Moisture on the skin can compromise the adhesive seal and lead to skin irritation. Therefore, the skin should be thoroughly dried before applying the ostomy pouching system.
Choice D rationale:
Tracing the size of the stoma onto the skin barrier is the correct technique when changing an ostomy appliance. The opening of the skin barrier (wafer) should match the size and shape of the stoma to ensure a proper fit. Tracing the stoma's size onto the barrier helps in cutting the opening to the appropriate size, preventing leakage and ensuring a secure fit around the stoma.
Correct Answer is A
Explanation
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