An older adult client is brought to an urgent care clinic by her paid in-home caregiver for a suspected UTI. The client has bruising to the left side of her face and appears fearful when her caregiver makes sudden movements. Which priority action should the nurse take first?

Notify adult protective services about possible elder abuse by the caregiver.

Have the caregiver stay in the waiting area while the client is brought into a room for assessment.

Contact the caregiver's employment agency to report the suspicion of abuse.

Ask the patient how the injury occurred and observe the caregiver's reaction.

Answer and Explanation

The Correct Answer is B

A.   This action is crucial if there is a suspicion of elder abuse, as adult protective services (APS) can investigate the situation thoroughly and take necessary measures to protect the client. However, before making such a notification, it is important to assess the immediate safety of the client and gather preliminary information.
B.   This is a prudent initial action to ensure that the client is in a safe environment away from the caregiver, who may be the suspected abuser. It allows the nurse to conduct a private and thorough assessment of the client without the potential influence or intimidation from the caregiver. This step is critical for ensuring the client's safety and obtaining unbiased information.
C.   While reporting to the caregiver’s employment agency may be a step in the process, it is not the immediate priority. The primary focus should be on ensuring the client’s safety and assessing the situation before contacting external agencies.
D.   While it is important to gather information about how the injury occurred, the immediate priority is to ensure the client's safety and provide an opportunity for a private assessment. The presence of the caregiver during this conversation could influence the client's responses or cause additional stress.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. This would indicate adrenal insufficiency, not Cushing syndrome.
B. Elevated adrenocorticotropic hormone (ACTH) and elevated cortisol would indicate Cushing syndrome caused by pituitary adenoma, not adrenal gland hyperplasia.
C. Low adrenocorticotropic hormone (ACTH) and elevated cortisol is consistent with Cushing syndrome caused by adrenal gland hyperplasia. In this condition, the adrenal glands produce excess cortisol independently of ACTH stimulation.
D. Elevated adrenocorticotropic hormone (ACTH) and low cortisol would indicate adrenal insufficiency, not Cushing syndrome.

A. Guillain-Barre Syndrome is a contagious disease spread by respiratory droplets. B. Guillain-Barre Syndrome causes demyelination in the central nervous system. C. Guillain-Barre Syndrome is a genetic disorder. D. Guillain-Barre Syndrome affects the peripheral nervous system.

Correct Answer is D

Explanation

A. Guillain-Barre Syndrome is not a contagious disease. It is an autoimmune disorder that occurs when the immune system mistakenly attacks the peripheral nerves. GBS is not spread through respiratory droplets or any other form of infection transmission.
B. Guillain-Barre Syndrome causes demyelination in the peripheral nervous system, not the central nervous system. The central nervous system includes the brain and spinal cord, whereas the peripheral nervous system comprises the nerves outside the brain and spinal cord.
C. Guillain-Barre Syndrome is not a genetic disorder. It is considered an autoimmune condition that can be triggered by an infection or other environmental factors. While there may be genetic predispositions that affect susceptibility to autoimmune conditions, GBS itself is not classified as a genetic disorder.
D. Guillain-Barre Syndrome primarily affects the peripheral nervous system. It involves an immune- mediated attack on the peripheral nerves, leading to symptoms such as muscle weakness, tingling, and loss of reflexes.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

An older adult client is brought to an urgent care clinic by her paid in-home caregiver for a suspected UTI. The client has bruising to the left side of her face and appears fearful when her caregiver makes sudden movements. Which priority action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a diagnosis of Cushing syndrome. After performing magnetic resonance imaging (MRI), the underlying cause of the condition is found to be hyperplasia of the adrenal glands. Which of the following lab results would the nurse anticipate with this condition?

Correct Answer is C

Explanation

A nurse educator is providing an educational in-service about various neurological disorders. Which statement should be included when teaching about Guillain-Barre Syndrome?

Correct Answer is D

Explanation

The nurse is performing an admission assessment on a client who is being admitted for right- sided heart failure. Which statement made by the patient would be consistent with right-sided heart failure?

An older adult client is brought to an urgent care clinic by her paid in-home caregiver for a suspected UTI. The client has bruising to the left side of her face and appears fearful when her caregiver makes sudden movements. Which priority action should the nurse take first?

A client who received a kidney transplant 3 months ago is in the nephrologists office for a follow up appointment. Which finding would indicate that the client is experiencing a complication which is common after a kidney transplant?

A nurse is providing education to a group of older adults about the signs and symptoms of a myocardial infarction. Which of the following is not a sign of a myocardial infarction?

A client is in the oliguric phase of acute kidney injury (AKI) which was caused by massive tissue trauma. The nurse notes peaked T-waves and a widened QRS complex on the cardiac monitor. What is the first action the nurse should take?

A miotic medication has been prescribed for a client with acute angle-closure glaucoma. The client asks the nurse about the purpose of the medication. Which response should the nurse provide to the client?

A nurse is reviewing the medical record of a client who has been on levothyroxine for several months. Which of the following findings indicates a therapeutic response to the medication?