As a result of the Adult Protective Services investigation, additional care has been established for the client including physical and occupational therapy twice weekly and a home health aide to provide assistance with activities of daily living.

Select from statement options to complete the sentence.

To assess outcomes, the nurse should consider information reported by the client and caregiver and focus on evaluating the client's

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A. Administer oxygen 5 L/minute via simple face mask: Oxygen administration is a priority intervention to improve oxygenation and address the client's low oxygen saturation of 82%.
Hypoxemia can lead to tissue hypoxia and further compromise the client's condition. Therefore, administering oxygen should be the first action taken to ensure an adequate oxygen supply to vital organs.
B. Bacitracin applied topically to lacerations every 12 hours: While wound care is important, administering oxygen and establishing IV access take precedence over topical
treatment. Oxygenation and fluid resuscitation are critical in the immediate management of a trauma patient to ensure adequate tissue perfusion and oxygen delivery.

C. Place 2 large bore peripheral IV's: Establishing IV access is essential for administering medications and fluids rapidly. This is particularly important in this scenario where the client may require immediate fluid resuscitation due to hypotension (blood pressure of 83/41 mm Hg).
Large bore IV access allows for rapid infusion of fluids and medications to stabilize the client's hemodynamic status.

D. X-ray of the right arm and cervical spine: While diagnostic imaging is important for assessing injuries, it is not as urgent as administering oxygen and establishing IV access. Oxygenation and fluid resuscitation are higher priorities to stabilize the client's condition before proceeding with diagnostic tests.

E. Computed tomography scan of the brain: While a CT scan of the brain is essential for assessing potential head injuries, the immediate focus should be on stabilizing the client's oxygenation and hemodynamic status. Administering oxygen and fluids take precedence over diagnostic imaging to address the client's hypoxemia and hypotension.

F. Vital signs every 1 hour: Monitoring vital signs is important for ongoing assessment, but it is not as urgent as administering oxygen and fluids. Vital signs should be monitored closely, but immediate interventions to address hypoxemia and hypovolemia are critical to stabilize the client's condition.

G. Give 1 Liter bolus of 0.9% sodium chloride solution IV once: The client's hypotension (blood pressure of 83/41 mm Hg) indicates hypovolemia and the need for fluid resuscitation. Administering a bolus of intravenous fluids (1 Liter bolus of 0.9% sodium chloride solution) is essential to address hypovolemia and improve perfusion to vital organs. This intervention helps stabilize the client's blood pressure and prevent further deterioration of her condition.

• Short-term memory loss: While some degree of memory loss can be a normal part of aging, significant short-term memory loss in the context of elder mistreatment can indicate neglect or psychological abuse. It might reflect isolation or a lack of proper mental stimulation and care.

• Pressure injuries: These are clear indicators of neglect. Pressure injuries, such as bedsores, occur when a person is not moved or repositioned regularly. They can suggest that the caregiver is not providing adequate care or attention to the client's physical needs.

• Malnutrition: This is a strong sign of neglect. Malnutrition, evidenced by loss of subcutaneous fat and low body weight, indicates that the client is not receiving adequate nutrition. This could be due to neglect in providing food or a lack of attention to dietary needs, which is a form of mistreatment.