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.
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Correct Answer is C
Explanation
This would help the client to feel valued, respected and involved in their own care, which can enhance their self-esteem.
Choice A is wrong because adding a nursing diagnosis of lowered self-esteem to the care plan does not address the underlying causes of the problem or provide any interventions to improve it.
It may also label the client and make them feel worse.
Choice B is wrong because giving praise for every decision the client makes is not realistic or sincere.
It may also undermine the client’s confidence and autonomy by implying that they need constant approval from others.
Choice D is wrong because modeling competent care for the client does not necessarily help them to maintain their self-esteem.
It may even make them feel inadequate or dependent on the nurse.
Correct Answer is D
Explanation
Insulin regular (Humulin-R) is the only form of insulin that is safe for intravenous administration. This is because it is a short-acting insulin that has a rapid onset and peak time, and does not contain any additives or suspensions that could interfere with the infusion.
Choice A is wrong because insulin aspart (Novo Log) is a rapid-acting insulin that is usually taken right before a meal. It is not suitable for intravenous use because it has a different amino acid sequence than human insulin.
Choice B is wrong because insulin glargine (Lantus) is a long-acting insulin that covers insulin needs for about a full day. It is not suitable for intravenous use because it forms micro-precipitates under the skin that release insulin slowly and steadily.
Choice C is wrong because insulin lispro (Humalog) is a rapid-acting insulin that is usually taken right before a meal. It is not suitable for intravenous use because it has a different amino acid sequence than human insulin.
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