A nurse is caring for a 26-year-old gravida 2 para 1 client in the labor and delivery unit.

Exhibits

Click to indicate which interventions the nurse would include in the plan of care to support the expected outcomes of adequate epidural anesthesia on the mother and the fetus. Each column must have at least one response selected.

Choice A rationale

Short-term memory loss is not typically associated with elder mistreatment. It may result from normal aging, neurological conditions like Alzheimer's disease, or other medical issues affecting cognitive function. It does not directly indicate mistreatment.

Choice B rationale

Malnutrition in the elderly can be a sign of neglect or mistreatment, where the individual may not receive adequate nutrition due to inadequate caregiving or intentional withholding of food. It can lead to severe health complications and indicates a lack of proper care.

Choice C rationale

Bilateral leg edema can result from various medical conditions, such as heart failure, chronic venous insufficiency, or renal disease. It is not a specific indicator of elder mistreatment and requires a thorough medical evaluation to determine the underlying cause.

Choice D rationale

Diminished breath sounds are typically related to respiratory conditions, such as pneumonia, chronic obstructive pulmonary disease (COPD), or pleural effusion. While they require medical attention, they do not directly indicate elder mistreatment.

Choice E rationale

Dark room lighting can suggest poor living conditions and inadequate care, potentially indicating neglect or mistreatment. Proper lighting is essential for the safety and well-being of elderly individuals, and its absence may reflect a lack of proper care and attention.

Choice F rationale

Poor hygiene is a common sign of neglect in elder mistreatment cases. It indicates that the individual may not receive assistance with personal care, leading to physical and emotional distress. Neglecting hygiene needs can result in infections and other health issues.

Choice G rationale

Pressure injuries, or bedsores, are often a result of prolonged immobility and inadequate repositioning, which can occur in cases of elder mistreatment or neglect. These injuries can lead to severe complications and are indicative of a lack of proper care and attention to the individual's needs.

Choice A rationale

Noting the date and time of the behavior is the first step in addressing the issue, providing a record for future reference and ensuring accuracy in documentation.

Choice C rationale

Planning for scheduled break times helps address potential reasons for the behavior, offering a structured solution to prevent recurrence and improve overall workflow.

Choice B rationale

Evaluating the UAP for signs of improvement is the final step, assessing whether the implemented interventions have been effective and if further actions are needed.