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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 A

Explanation

Choice A rationale

Withholding the dose is the safest action to avoid potential overdose or toxicity. Digoxin has a narrow therapeutic window, and administering an additional dose without knowing how much was absorbed could lead to dangerous side effects.

Choice B rationale

Administering a half dose now is not recommended because it is unclear how much of the original dose was absorbed. This could result in either an insufficient dose or an overdose, leading to ineffective treatment or potential toxicity.

Choice C rationale

Giving another dose is not safe because there is a risk of overdosing the infant. Digoxin toxicity can cause serious complications, and it is crucial to avoid administering more medication until the next scheduled dose.

Choice D rationale

Mixing the next dose with food is not appropriate because it does not address the immediate concern of potential overdose. The priority is to withhold the dose and monitor the infant's condition.

A. Paresthesia. B. Tremors. C. Tinnitus. D. Fever. E. Tachycardia.

Correct Answer is ["D","E"]

Explanation

Choice A rationale

Paresthesia, or abnormal sensations such as tingling or numbness, is a common symptom of multiple sclerosis (MS) due to the demyelination of nerve fibers in the central nervous system. While it can be bothersome for the client, it is not typically an immediate life-threatening condition that requires urgent reporting to the healthcare provider. Ongoing management and monitoring of symptoms are important, but paresthesia alone does not necessitate immediate medical intervention.

Choice B rationale

Tremors are another common manifestation of MS, resulting from nerve damage that affects motor pathways. Tremors can significantly impact the client's quality of life, making daily activities challenging. However, like paresthesia, tremors are not usually considered an urgent condition that needs immediate reporting. They should be managed through a comprehensive care plan involving medications and physical therapy.

Choice C rationale

Tinnitus, or ringing in the ears, can occur in individuals with MS due to demyelination affecting the auditory pathways. While tinnitus can be distressing and affect the client's hearing, it is not typically an immediate life-threatening condition. It may require evaluation and symptomatic management, but it does not require urgent reporting unless it is associated with other severe symptoms.

Choice D rationale

Fever in a client with MS could indicate an infection or other inflammatory process, which can exacerbate MS symptoms and lead to a relapse. Fever may also signal a secondary complication such as a urinary tract infection or respiratory infection, which requires prompt medical attention. The healthcare provider should be notified immediately to evaluate and manage the underlying cause of the fever.

Choice E rationale

Tachycardia, or an abnormally rapid heart rate, can be a sign of several serious conditions, including infection, dehydration, or cardiovascular problems. In clients with MS, tachycardia may also indicate an autonomic dysfunction or be a response to fever or other stressors. Immediate reporting to the healthcare provider is necessary to determine the underlying cause and initiate appropriate treatment to prevent complications.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

Correct Answer is A

Explanation

The nurse is completing the admission assessment of a client with multiple sclerosis (MS). Which finding(s) should be reported to the healthcare provider immediately? Select all that apply.

Correct Answer is ["D","E"]

Explanation

A client with hemorrhoids asks for information about a high fiber diet. Which breakfast menu item(s) should the nurse suggest? Select all that apply.

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?

A female client is taking alendronate, a bisphosphonate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?

Exhibits The nurse is reviewing the client's data. Which of the following findings should the nurse report to the primary health care provider immediately? Select all that apply.

The nurse observes an unlicensed assistive personnel (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?

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.