A nurse is assessing an older adult client who was brought to the emergency department by his adult son, who reports that the client fell at home. The nurse suspects elder abuse. Which of the following actions should the nurse take?

Ask the client's son to go to the waiting area.

Ask the client about his injuries with the son present.

Treat and discharge the client.

File an incident report.

Answer and Explanation

The Correct Answer is A

A.   Asking the client's son to go to the waiting area allows the nurse to have a private conversation with the client, which is crucial in suspected cases of elder abuse to gather information without potential interference or intimidation.
B.   Asking about injuries with the son present might hinder the client from disclosing information due to fear or pressure.
C.   Treating and discharging the client without addressing the suspected elder abuse could potentially put the client in further danger.
D.   Filing an incident report might be necessary but should follow an assessment and investigation of the situation.

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Correct Answer is C

Explanation

- A: While resolving conflicts is important to maintain a healthy work environment, it may not immediately affect patient care and safety.
- B: Client preferences should be respected, but this situation can usually be resolved by reassigning staff without immediate risk to patient safety.
- C: Staff absences can critically impact patient care due to inadequate staffing, which can lead to increased workload for present staff and compromise patient care.
- D: Transport issues, although they need to be addressed, do not usually pose an immediate threat to patient safety compared to inadequate staffing. Physical therapy can often be rescheduled without significant harm to the patient.

A. Inform the unit manager of the incident. B. Speak with the AP about the incident. C. Remove the restraints from the client's wrists. D. Review the chart for nonrestraint alternatives for agitation,

Correct Answer is C

Explanation

A. Informing the unit manager is essential but not the first immediate action when a client is improperly restrained.
B. Speaking with the AP about the incident is important, but the priority is to ensure the client's safety and well-being.
C. Removing the restraints from the client's wrists is the first action to address the
inappropriate application of restraints without a prescription to ensure the client's safety and prevent harm.
D. Reviewing the chart for nonrestraint alternatives for agitation is important, but the priority is to address the immediate issue of the improperly applied restraints to the client.

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A nurse is assessing an older adult client who was brought to the emergency department by his adult son, who reports that the client fell at home. The nurse suspects elder abuse. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse manager is receiving report and is faced with the following situations that require intervention. Which of the following should the nurse manager address first?

Correct Answer is C

Explanation

A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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