A nurse is caring for an older adult client who states, "I can't pay for my care because my kid took all my money." Which of the following actions should the nurse take?

Instruct the client to report the theft to the police.

Report the possible abuse to adult protective services.

Ask the client if there is another family member they can call for financial help.

Restrict visitation for the client's family until discharge.

Answer and Explanation

The Correct Answer is B

A. Instructing the client to report the theft to the police might be appropriate in cases of theft, but the nurse's primary responsibility is to ensure the safety and well-being of the client. Reporting
to the authorities can be pursued after ensuring the client's immediate safety.

B.   Reporting the possible abuse to adult protective services is the appropriate action when financial exploitation or abuse is suspected. Adult protective services can investigate the situation and provide support and resources to ensure the client's safety.
C.   Asking the client if there is another family member they can call for financial help is a valid consideration, but it does not address the potential abuse or exploitation of the client's finances.
D.   Restricting visitation for the client's family until discharge is not appropriate without further assessment and intervention. It may also isolate the client from potential sources of support and assistance.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Using an adhesive remover can help safely and effectively remove the adhesive residue from the skin without causing irritation or damage.
B. Scrubbing the skin around the colostomy can cause skin irritation and increase the risk of skin breakdown. Gentle cleaning with warm water and mild soap is recommended.
C. Most colostomy bags do not require suctioning of stool, as they are designed to collect fecal matter without the need for suctioning.
D. It is generally recommended to empty the colostomy bag when it is about one-third to one- half full to prevent leakage and maintain skin integrity.

A. A client who has a history of pancreatitis and reports severe abdominal pain B. A client who has heart failure and reports severe dyspnea C. A client who is scheduled for abdominal surgery in 1 hr D. A postoperative client who has diabetes mellitus and a blood glucose of 280 mg/dL

Correct Answer is B

Explanation

A. While severe abdominal pain in a client with a history of pancreatitis requires urgent assessment, severe dyspnea in a client with heart failure may indicate impending respiratory distress, requiring immediate intervention.
B. Severe dyspnea in a client with heart failure is a critical situation that requires immediate assessment and intervention to prevent respiratory compromise or failure.
C. While a client scheduled for surgery may need preparation and assessment, the client with severe dyspnea takes priority due to the potential for respiratory distress.
D. While a high blood glucose level in a postoperative client with diabetes mellitus requires monitoring and intervention, the client with severe dyspnea requires immediate attention due to the potential for respiratory compromise.

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A nurse is caring for an older adult client who states, "I can't pay for my care because my kid took all my money." Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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