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.

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Correct Answer is D

Explanation

A. Cushing syndrome is characterized by excessive levels of cortisol in the body, often due to an adrenal gland tumor or prolonged use of corticosteroid medications. The primary symptoms include weight gain, hypertension, and changes in skin appearance. Exophthalmos is not typically associated with Cushing syndrome.
B. Hashimoto's disease is an autoimmune thyroid disorder that leads to hypothyroidism (underactive thyroid). The condition is characterized by symptoms such as fatigue, weight gain, cold intolerance, and dry skin. Exophthalmos is not a feature of Hashimoto's disease. Instead, it is more commonly associated with hyperthyroidism.
C. Addison's disease is a condition caused by inadequate production of cortisol and aldosterone by the adrenal glands. Symptoms include fatigue, weight loss, hyperpigmentation of the skin, and low blood pressure. Exophthalmos is not related to Addison's disease.
D. Graves' disease is an autoimmune hyperthyroid condition that leads to an overproduction of thyroid hormones. One of the hallmark symptoms of Graves' disease is exophthalmos or protruding eyes, caused by inflammation and swelling of the tissues around the eyes. This condition is directly associated with exophthalmos.

A. Phacoemulsification B. Extracapsular cataract extraction C. Cochlear implant D. Surgical iridectomy

Correct Answer is D

Explanation

A. Phacoemulsification is a procedure used to remove cataracts from the eye. It involves using ultrasound waves to break up the cloudy lens (cataract) into small fragments, which are then suctioned out. While this procedure is relevant for cataract treatment, it does not address the acute management of angle-closure glaucoma.
B. Extracapsular cataract extraction is a surgical procedure to remove a cataract from the eye by making an incision and extracting the lens in one piece or in large segments. Like phacoemulsification, this procedure is focused on cataract removal and does not directly treat the underlying issue of acute angle-closure glaucoma.
C. A cochlear implant is a device used to provide a sense of sound to individuals with severe hearing loss or deafness. This procedure is unrelated to the treatment of eye conditions or intraocular pressure and therefore is not appropriate for managing primary angle-closure glaucoma.
D. Surgical iridectomy is a procedure specifically aimed at treating angle-closure glaucoma. It involves creating a small hole (iridectomy) in the peripheral iris to allow aqueous humor to flow from the posterior chamber of the eye to the anterior chamber, bypassing the obstructed drainage angle.

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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

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Correct Answer is D

Explanation

Correct Answer is D

Explanation

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