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 The client is oriented times four, but is despondent and withdrawn.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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Diaper changes help assess the baby’s urinary output and general hydration status. If the newborn is producing urine, it suggests proper kidney function and adequate fluid intake, which are essential considerations before transferring the baby to the nursery.
B. While this promotes bonding and allows the mother to assess her baby visually, it does not directly address health indicators such as feeding or elimination, which are critical for ensuring the newborn’s well-being.
C. Noting if the baby is sleeping is a routine observation but does not address the importance of maternal bonding.
D. Whether the family has seen the baby is less critical than ensuring the mother has had early bonding opportunities.
Correct Answer is D
Explanation
A. Administering cholera vaccines can help prevent further cases but is not the immediate priority for those already infected.
B. Administering prophylactic antibiotics is important but not the highest priority compared to addressing the acute symptoms of cholera.
C. Isolating all infectious diarrhea victims helps prevent the spread of infection but does not address the immediate life-threatening dehydration and electrolyte imbalance.
D. Providing fluid and electrolyte replacement is the highest priority as cholera causes severe dehydration and electrolyte imbalance, which can be fatal if not treated promptly. Immediate rehydration is crucial to save lives.
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