A son brings his elderly mother to the emergency department and states that she fell today. The nurse notes multiple bruises in all stages of healing all over the client’s body. Which action should the nurse take first?.
Provide an elder abuse brochure and teach the client.
Interview the client privately and ask if anyone is harming her.
Observe the interaction between the mother and the son throughout stay.
Report the abuse without confirming
The Correct Answer is B
Interview the client privately and ask if anyone is harming her.
This is because the nurse has a duty to assess the client for possible elder abuse and report any suspicions to the appropriate authorities.
The nurse should not assume that the son is the abuser or that the client will disclose the abuse without being asked directly.
The nurse should also respect the client’s autonomy and privacy and not confront the son or provide an elder abuse brochure without the client’s consent.
Choice A is wrong because it may imply that the client is responsible for preventing the abuse or that the nurse has already made a judgment about the situation.
It may also be ineffective if the client is unable or unwilling to read the brochure or seek help. Choice C is wrong because it may delay the assessment and intervention for the client.
It may also be biased and unfair to observe the son without interviewing him or the client first.
Choice D is wrong because it may violate the client’s rights and preferences.
It may also be premature to report the abuse without confirming it with the client or obtaining more evidence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Inspection, palpation, percussion, and auscultation are the four techniques used to perform a physical assessment.
Inspection involves observing the patient’s appearance, posture, movement, and behavior. Palpation involves feeling the patient’s skin, organs and pulses with the hands.
Percussion involves tapping the patient’s body with the fingers or a small hammer to elicit sounds or vibrations.
Auscultation involves listening to the patient’s heart, lungs, and bowel sounds with a stethoscope.
Choice A is wrong because relationship and evaluation are not techniques of physical assessment.
Relationship refers to the rapport and trust established between the nurse and the patient.
Evaluation refers to the process of comparing the expected outcomes with the actual outcomes of the nursing interventions.
Choice C is wrong because vital signs, health history, general survey, and height and weight are not techniques of physical assessment.
They are components of a health assessment, which is a broader term that includes physical assessment as well as other aspects of the patient’s health status.
Choice D is wrong because color is not a technique of physical assessment.
Color is an aspect of inspection, which is one of the techniques of physical assessment.
Correct Answer is D
Explanation
pc stands for post cibum, which means after meals in Latin. This abbreviation indicates that a medication is to be administered after the patient has eaten.
Choice A is wrong because hs stands for hora somni, which means at bedtime in Latin. This abbreviation indicates that a medication is to be administered before the patient goes to sleep.
Choice B is wrong because prn stands for pro re nata, which means as needed in Latin. This abbreviation indicates that a medication is to be administered only when the patient requires it.
Choice C is wrong because ac stands for ante cibum, which means before meals in Latin. This abbreviation indicates that a medication is to be administered before the patient eats.
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