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A nurse is caring for an 84-year-old female client in her home to establish home health care and perform an initial assessment.

Exhibits
Which intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.

Develop a safety plan.

Perform a thorough physical assessment.

Report findings to Adult Protective Services.

Confront the abuser about concerning actions.

Take photographs to document the abuse or neglect.

Complete a comprehensive history.

Throw away soiled clothing.

Query the client in front of the suspected abuser.

Answer and Explanation

Correct Answer : A,B,C,E,F

Choice A rationale: Developing a safety plan is essential to ensure the client's immediate and long-term safety. This involves planning for safe living arrangements and other protective measures.

Choice B rationale: Performing a thorough physical assessment helps document the extent of injuries or neglect and provides critical information for further actions and interventions.

Choice C rationale: Reporting findings to Adult Protective Services is a necessary step to ensure that the client receives the appropriate protection and support from authorities.

Choice E rationale: Taking photographs to document the abuse or neglect provides visual evidence that can be used in investigations and legal actions to protect the client.

Choice F rationale: Completing a comprehensive history helps understand the full context of the client's situation, including past medical history, social support, and potential risk factors for mistreatment.

Choice D rationale: Confronting the abuser about concerning actions is not advisable as it can escalate the situation and put the client at greater risk.

Choice G rationale: Throwing away soiled clothing may destroy potential evidence and is not a priority intervention in the context of suspected elder mistreatment.

Choice H rationale: Querying the client in front of the suspected abuser can intimidate the client and prevent them from speaking freely about their situation.

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Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"C"}

Explanation

Rationale for correct answer:

Pain relief: The purpose of epidural anesthesia is to provide pain relief during labor. Since the nurse’s notes state that the client is comfortable and reports adequate pain relief, it demonstrates that the epidural anesthesia is effective.
Fetal heart rate: Monitoring fetal heart rate is crucial to ensure the well-being of the baby during labor. The nurse’s notes state that the fetal heart rate is within normal limits, indicating that the epidural anesthesia has not adversely affected the baby and is working effectively.

Rationale for incorrect answers:

Good urine output: While good urine output is important, it is not a direct indicator of the effectiveness of epidural anesthesia. It does not provide information about pain relief or fetal well-being.
Vital signs: Vital signs are important to monitor but do not specifically indicate the effectiveness of epidural anesthesia in terms of pain relief and fetal well-being.
Progression of labor: The progression of labor is influenced by various factors, not just the effectiveness of epidural anesthesia. It is not a direct measure of the epidural’s effectiveness.
Labor augmentation: Labor augmentation refers to interventions to stimulate labor. It is not related to the effectiveness of epidural anesthesia.

A. Ask the mother what she usually uses on the child's lips and nose. B. Use a topical lidocaine analgesic for cracked lips. C. Apply a petroleum jelly to the child's nose and lips. D. Use a water-soluble lubricant on affected oral and nasal mucosa.

Correct Answer is D

Explanation

Choice A rationale

Asking the mother about usual care practices might provide useful information, but it is not the best immediate intervention for addressing the child's dry and cracked lips and nares. Immediate action should be taken to provide relief.

Choice B rationale

Using a topical lidocaine analgesic is not appropriate for treating dryness and cracking of the lips and nares. Lidocaine is an anesthetic, not a moisturizing agent, and could cause additional irritation or adverse reactions if used improperly.

Choice C rationale

Applying petroleum jelly to the child's nose and lips is not recommended as it poses a risk of aspiration, especially in young children. Inhaling petroleum jelly can lead to respiratory issues and is therefore not a safe option.

Choice D rationale

Using a water-soluble lubricant is the best option for moisturizing and protecting the child's dry and cracked lips and nares. Water-soluble lubricants are safe for use on mucous membranes and provide effective relief without the risk of aspiration.

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A nurse is caring for an 84-year-old female client in her home to establish home health care and perform an initial assessment. Exhibits Which intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a 26-year-old gravida 2 para 1 client in the labor and delivery unit. Exhibits Drag from the Word Choices to complete the sentence. The client demonstrates effective epidural anesthesia by:dropdown and dropdown

Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"C"}

Explanation

While caring for a toddler receiving oxygen via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement?

Correct Answer is D

Explanation

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Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this client's plan of care?

The nurse recognizes that findings consistent with elder mistreatment.

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The nurse is preparing to administer a formula feeding by nasogastric tube (NGT) to a 2-month-old. Which intervention should the nurse implement?

A nurse is caring for an 84-year-old female client in her home to establish home health care and perform an initial assessment.

Exhibits
Which intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.