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
This is because anti-embolism stockings are designed to prevent swelling and blood clots in the legs by applying graduated compression, which is tighter around the ankle and looser as it moves up the leg. Applying the stockings in the morning before any swelling occurs ensures a proper fit and optimal blood flow.
Choice A is wrong because massaging the legs can dislodge a blood clot and cause a pulmonary embolism.
Choice C is wrong because wetting the stockings can make them harder to apply and reduce their effectiveness.
Choice D is wrong because removing the stockings before bathing can increase the risk of swelling and clotting, and applying fresh ones afterward can be difficult and uncomfortable.
Correct Answer is D
Explanation
Collaborate with the prescriber about the order. This is because the nurse has a responsibility to ensure the safety and effectiveness of the medication administration and to question any orders that seem inappropriate or unclear. The nurse should not administer the medication as ordered without verifying it first, as this could cause harm to the client or result in a medication error. The nurse should not check to see if previous shift nurses gave the medication, as this does not address the issue of the current order and could lead to missed or duplicated doses. The nurse should not administer only the standard dose of the medication, as this could be against the prescriber’s intention and could compromise the client’s treatment or outcome.
Choice A is wrong because it does not follow the principle of safe medication administration and could put the client at risk of adverse effects or overdose.
Choice B is wrong because it does not respect the prescriber’s authority and could result in underdosing or ineffective therapy for the client.
Choice C is wrong because it does not solve the problem of the current order and could cause confusion or inconsistency in the medication administration.
Choice D is correct because it demonstrates critical thinking and professional accountability, and ensures that the order is appropriate and accurate for the client’s condition and needs.
The normal ranges for medication dosages depend on various factors, such as the type of medication, the route of administration, the client’s age, weight, renal function, liver function, and other comorbidities.
The nurse should always consult reliable sources of information, such as drug guides, pharmacists, or prescribers, to determine the safe and effective dosages for each client
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