Case2/6

Exhibits

To start the client on oxygen as ordered, what item(s) should the nurse collect from the supply room? Select all that apply.

A. Increase in respiratory rate: An increase in respiratory rate may indicate respiratory distress or worsening condition, not necessarily the effectiveness of CPT.
B. Absence of coarse crackles: Coarse crackles are indicative of secretions in the airways. Their absence after CPT indicates that the therapy has helped mobilize and clear the secretions.
C. Absence of fine crackles: Fine crackles might be present due to other issues, so their absence does not directly indicate the effectiveness of CPT in mobilizing secretions.
D. Increase in breath sounds: An increase in breath sounds alone does not necessarily indicate the effectiveness of CPT in mobilizing secretions.

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.