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Case 4/6
Exhibits
What intervention(s) should the nurse initate if elder mistreatment is suspected? Select all that apply.

Develop a safety plan.

Confront the abuser about concerning actions.

Throw away soiled clothing.

Perform a thorough physical assessment.

Complete a comprehensive history.

Report findings to Adult Protective Services.

Take photographs to document the abuse or neglect.

Question the client in front of the suspected abuser.

Answer and Explanation

Correct Answer : A,D,E,F

A. Develop a safety plan.
o   Reason: A safety plan addresses immediate concerns and ensures the client's protection. It involves creating a strategy for what the client can do if mistreatment continues, including safe contacts and emergency procedures.
D. Perform a thorough physical assessment.
o   Reason: A comprehensive physical assessment helps identify signs of abuse or neglect and gathers evidence for further action. It’s essential to document any physical findings related to mistreatment.
E. Complete a comprehensive history.
o   Reason: A detailed history provides context for the client’s current condition and any changes in their care. It helps to identify patterns of neglect or abuse and understand the full scope of the client’s experience.
F. Report findings to Adult Protective Services.
o   Reason: Reporting to Adult Protective Services is a legal and ethical obligation to ensure that elder mistreatment is investigated and addressed by professionals. It is crucial for initiating formal investigation and intervention processes.
Not Selected Interventions:
B. Confront the abuser about concerning actions.
•   Reason: Confrontation may escalate the situation or place the client at greater risk. It’s more appropriate to document findings and report them to authorities who can handle the situation professionally.
C. Throw away soiled clothing.
•   Reason: Disposing of soiled clothing is not an appropriate response to suspected mistreatment and may destroy evidence of neglect or abuse.
G. Take photographs to document the abuse or neglect.
•   Reason: While documenting findings is important, photographs should be taken by professionals in a way that respects legal and ethical standards. This action is usually performed by investigators rather than the nurse.
H. Question the client in front of the suspected abuser.
•   Reason: Asking the client about mistreatment in the presence of the suspected abuser can be unsafe and might result in further harm to the client. Private and safe environments are required for sensitive questioning.

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Correct Answer is C

Explanation

A. Obtain client's vital signs every 4 hours when awake: While monitoring vital signs is essential, it is not the most immediate concern related to the medication management and adjustment to a new environment.
B. Measure and record the client's urinary output every day: While important for monitoring fluid balance, this action is not as directly related to the client's adjustment to a new environment or immediate medication effects.
C. Obtain a blood pressure reading before the client gets out of bed: Blood pressure should be monitored before the client stands up, especially when they are on a new sedative medication, to prevent orthostatic hypotension and ensure safe transitions.
D. Provide the client with teaching regarding a cardiac diet: Teaching about a cardiac diet is important but is not as immediately relevant as ensuring the client's safety and stability with their new medications and environment.

A. Assign the UAP to provide care for another client and assume full care of the client. B. Instruct the UAP to notify the nurse of any changes in the client's respiratory status. C. Review the need for the UAP to wear a face mask while in close contact with the client. D. Remind the UAP to apply a fitted respirator mask before entering the client's room.

Correct Answer is D

Explanation

A. Assign the UAP to provide care for another client and assume full care of the client: This action is excessive since the UAP is using appropriate personal protective equipment for the situation.
B. Instruct the UAP to notify the nurse of any changes in the client's respiratory status: While important, it is not the immediate concern here.
C. Review the need for the UAP to wear a face mask while in close contact with the client: A face mask is needed, but the correct type of mask for influenza is a fitted respirator.
D. Remind the UAP to apply a fitted respirator mask before entering the client's room: Influenza requires the use of a fitted respirator mask (N95) in addition to gloves and gown to prevent droplet transmission

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Case 4/6 Exhibits What intervention(s) should the nurse initate if elder mistreatment is suspected? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

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Explanation

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Case 4/6
Exhibits
What intervention(s) should the nurse initate if elder mistreatment is suspected? Select all that apply.