A nurse is caring for a newly admitted older adult client.
Nurses' Notes
Day 1, 12:00:
Transferred to the medical-surgical unit from the emergency department (ED) for continued care following a closed reduction and immobilization of a fracture of the right arm. Accompanied by an adult child.
Client in visibly soiled night clothes with multiple stains, including what appears to be dried blood. Hair, teeth, and fingernails unclean. Strong body odor noted. Bruising of various stages noted around upper arms, back, shoulders, and neck area.
The client is soft-spoken, speaks almost in a whisper, and does not make eye contact with the nurse.
The client looks at their child before answering the nurse's questions and, when asked how the injury occurred, mumbles "I don't know. Ask them." The client's child states, "He gets confused sometimes. I can answer your questions."
Which of the following interventions should the nurse recommend to include in the client's plan of care?
Select all that apply.
Tell the client's child that they will be reported for maltreatment of the client.
Ask the client's child to provide details regarding the client's fractured arm.
Discuss respite care options with the client's child.
Speak to the client privately.
Provide legal advice to the client regarding the power of attorney.
Correct Answer : B,C,D
It is not appropriate for the nurse to threaten the client's child with reporting for maltreatment without further assessment and evidence.
Asking the client's child to provide details regarding the client's fractured arm will provide additional information about the client's injury and help the nurse assess the potential for abuse or neglect.
Discussing respite care options with the client's child may help alleviate any caregiver stress or burden, and ensure the client's continued care and safety.
Speaking to the client privately will help establish trust and rapport, and allow the client to disclose any
concerns or issues that they may not feel comfortable sharing in front of their child.
Providing legal advice regarding power of attorney is not within the scope of nursing practice and should be referred to a legal professional. Additionally, the client's capacity to make decisions and appoint a power of attorney should be assessed before providing such advice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E","F"]
Explanation
c. Report suspected maltreatment to the appropriate agency.
e. Ask the client how the fracture occurred.
f. Conduct the interview with the client privately.
In a situation where maltreatment is suspected, it is important for the nurse to report their concerns to the appropriate agency. The nurse should also ask the client how the fracture occurred and conduct the interview with the client privately, without the presence of their child, to gather more information and assess the situation.
Correct Answer is C
Explanation
c. New onset of hearing loss.
When collecting data from a client who is receiving gentamicin via IV infusion, the nurse should identify new onset of hearing loss as an adverse effect of the treatment¹. Gentamicin can cause vestibulocochlear nerve damage, which can affect hearing and balance¹.
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