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 A

Explanation

A. Elevated serum cholesterol is a common finding in hypothyroidism. The thyroid hormones play a role in regulating lipid metabolism, so low levels of thyroid hormones can lead to increased cholesterol levels. This is a typical finding in Hashimoto's disease, as it often results in hypothyroidism.
B. In Hashimoto's disease, which leads to hypothyroidism, TSH levels are usually elevated rather than low. TSH is produced by the pituitary gland and stimulates the thyroid gland to produce thyroid hormones (T3 and T4). When the thyroid gland is underactive and not producing enough hormones, the pituitary gland compensates by increasing TSH production. Therefore, a low TSH level would not be expected in Hashimoto's disease.
C. Free T4 (thyroxine) is typically low in hypothyroidism. Hashimoto's disease causes an underactive thyroid gland, which leads to decreased production of thyroid hormones, including free T4. Elevated free T4 would not be consistent with the diagnosis of Hashimoto's disease.
D. Elevated ACTH is more relevant to conditions involving the adrenal glands, such as Addison's disease or Cushing's syndrome. It is not a typical finding in Hashimoto's disease. Hashimoto's primarily affects thyroid function and does not directly impact ACTH levels.

A. "The sputum I have been coughing up is pink." B. "I feel short of breath when I lie down flat." C. "The nurse I had yesterday said she could hear fluid in my lungs." D. "Both of my legs are so swollen."

Correct Answer is D

Explanation

A. Pink, frothy sputum is typically associated with left-sided heart failure and pulmonary edema. This occurs when fluid backs up into the lungs due to left-sided heart failure. Since the question pertains to right-sided heart failure, this statement is not consistent with that condition.

B. Feeling short of breath when lying flat is known as orthopnea and is more commonly associated with left-sided heart failure. It occurs due to fluid shifting into the lungs when supine, which aggravates pulmonary congestion. This statement is not consistent with right-sided heart failure.
C. Hearing fluid in the lungs typically indicates left-sided heart failure, where fluid backs up into the pulmonary circulation, causing pulmonary edema. This symptom is associated with left-sided heart failure rather than right-sided heart failure.
D. Swelling of the legs, also known as peripheral edema, is a hallmark of right-sided heart failure. This occurs because the right side of the heart is unable to effectively pump blood out to the lungs, leading to fluid accumulation in the systemic venous circulation and resulting in swelling in the lower extremities and sometimes the abdomen

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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

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the laboratory results of a client who has a new diagnosis of Hashimoto's disease. Which of the following lab results would the nurse expect to find?

Correct Answer is A

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?

Correct Answer is D

Explanation

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