An older adult client is admitted to the hospital from a skilled care facility with dehydration and malnourishment. The client is oriented times four, but is despondent and withdrawn. The practical nurse (PN) observes that the client has multiple bruises on both arms and has poor hygiene. Which action should the PN implement first?
Document suspected abuse using the physical findings as supporting evidence.
Establish trust with the client to ensure basic needs and open communications are met.
Medicate the client as prescribed to ensure adequate rest and interventional therapies.
Contact social services to investigate the personnel at the skilled care facility.
The Correct Answer is B
A. While documentation is essential, establishing a trusting relationship with the client is a more immediate priority to address their basic needs and gather information.
B. Establishing trust with the client is crucial to ensure their basic needs are met and to create an environment where the client feels safe to communicate openly. This foundational step is necessary before other interventions can be effectively implemented.
C. Medicating the client as prescribed is important for their overall care but does not address the immediate need to build trust and assess their situation comprehensively.
D. Contacting social services is a necessary step if abuse is suspected, but it should follow the initial assessment and establishment of trust with the client to gather accurate information.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Pallor is not directly related to low serum calcium levels. It may indicate anemia or other conditions, but it is not a primary concern for hypocalcemia.
B. Bruising is generally associated with clotting issues or trauma, not specifically with low serum calcium. Low calcium can affect clotting, but bruising is not a direct or primary symptom of hypocalcemia.
C. Tetany, which includes symptoms like muscle spasms, twitching, and numbness, is a key indicator of low serum calcium levels. Monitoring for tetany is essential in managing clients with malabsorption syndrome who have hypocalcemia.
D. Jaundice is a sign of liver dysfunction or hemolysis, not directly related to low calcium levels. Low serum calcium is not typically associated with jaundice.
Correct Answer is B
Explanation
A. Maintaining low intermittent suction requires assessing the appropriate suction settings and monitoring for complications, which are responsibilities beyond the UAP’s scope of practice. This task involves clinical judgment and knowledge of suction settings.
B. Securing the tube to the client’s nose is a task that UAPs can perform. It is a straightforward task that helps ensure the tube stays in place, which is a supportive care measure within the UAP's scope of practice.
C. Ensuring correct placement of the tube involves assessing for proper tube position through methods such as aspirating gastric contents or using imaging, which are tasks that require clinical judgment and are outside the UAP's scope of practice.
D. Replacing the canister when full involves handling medical equipment and requires understanding of suction mechanics and infection control practices, which are tasks that the PN or RN should perform.
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