Try Naxlex NCLEX-RN (Free-Trial)

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale

The scenario indicates that the client's contractions are increasing in frequency and intensity, and she reports significant pain, prompting a request for an epidural. The cervical exam shows she is 5 cm dilated and 90% effaced, with the baby at 0 station, which is typical for the active phase of labor. This is the appropriate time for an epidural, as pain management is often needed when contractions become more intense and dilation progresses. Clear amniotic fluid after artificial rupture of membranes also suggests no immediate complications.

Choice B rationale

Immediate cesarean section is generally reserved for situations of fetal distress or other obstetric emergencies. There is no mention of fetal heart rate abnormalities or other signs of distress in the scenario. While MS can complicate pregnancy, it does not automatically necessitate a cesarean section without specific indications. The decision for cesarean should be based on maternal or fetal indications not present in this case.

Choice C rationale

The instruction to start pushing is only appropriate during the second stage of labor when the cervix is fully dilated (10 cm). The client is 5 cm dilated, indicating she is still in the active phase of the first stage of labor. Encouraging pushing at this stage would be premature and could cause unnecessary exhaustion and potential harm to the cervix and fetus. Pushing is typically reserved for the final stage when the baby's head is crowning.

Choice D rationale

Administering an epidural and experiencing immediate pain relief aligns with the standard protocol for labor analgesia when requested by the client. Epidural anesthesia is a common and effective method for pain management during labor. This option respects the client's expressed need for pain relief and involves the healthcare provider in safely administering the epidural. Immediate relief from pain can help the client focus on labor progression and reduce stress.

A. Lathering using a circular movement. B. Turning the water off using bare hands. C. Washing for a total of 20 seconds. D. Holding hands below elbows when rinsing. E. Holding hands below elbows when rinsing.

Correct Answer is B

Explanation

Choice A rationale

Lathering using a circular movement is an effective handwashing technique. This method ensures thorough coverage of all surfaces of the hands, including areas that are often missed, such as between the fingers and under the nails. The friction generated by the circular motions helps dislodge dirt, bacteria, and viruses from the skin. Proper lathering is a crucial step in reducing the microbial load on the hands and preventing the spread of infections.

Choice B rationale

Turning the water off using bare hands contaminates the hands after they have been washed. This action can reintroduce bacteria or viruses from the faucet handle back onto the clean hands, negating the benefits of handwashing. Proper hand hygiene protocol recommends using a paper towel or elbow to turn off the water to maintain the cleanliness achieved by washing. This step is critical in breaking the chain of infection transmission.

Choice C rationale

Washing hands for a total of 20 seconds is in line with the recommended guidelines from health organizations like the CDC. This duration is considered sufficient to effectively remove soil, dirt, and transient microorganisms from the skin. It allows enough time for the soap to act on contaminants and for mechanical action to dislodge them. Adhering to this time frame is an essential component of effective hand hygiene practices.

Choice D rationale

Holding hands below the elbows when rinsing ensures that water flows from the wrists down to the fingertips, effectively washing away soap and contaminants. This technique prevents recontamination of the hands by keeping the direction of water flow from the cleanest to the dirtiest areas. Proper rinsing is a key aspect of hand hygiene, ensuring that all soap residues, along with any remaining microorganisms, are thoroughly removed.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Correct Answer is A

Explanation

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?

Correct Answer is B

Explanation

A client expresses concern about receiving proper care in accordance with the client's religion. Which action is best for the nurse to take?

A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instruction(s) should the nurse give to the unlicensed assistive personnel (UAP) who is assisting with the client's care? Select all that apply.

A nurse is caring for a 24-year-old female client in the emergency department (ED). Exhibits What is the most likely diagnosis for this client, based on the history, physical exam, and diagnostic results?

The nurse is providing education to a client who receives a prescription for zolpidem. Which information about the medication should the nurse include?

A client expresses concern about receiving proper care in accordance with the client's religion. Which action is best for the nurse to take?

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?

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.

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.