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Exhibits

The nurse reviews the findings in the history and physical. Select from Word Choices to complete the sentence.

The nurse recognizes that

, and   are findings consistent with elder mistreatment.
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C","dropdown-group-3":"D"}

  • 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.


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Related Questions

Correct Answer is A

Explanation

A. Test the fluid on the dressing for glucose.
This is the correct action. Clear fluid on a dressing after lumbar spinal surgery could indicate a cerebrospinal fluid (CSF) leak. Testing the fluid for glucose is essential because CSF contains glucose, whereas normal wound drainage does not. A positive glucose test would confirm the presence of CSF, indicating a potential complication that requires immediate medical attention.

B. Mark the drainage area with a pen and continue to monitor.
While monitoring the size of the drainage area can be useful, it is not the immediate priority. The nurse should first determine whether the clear fluid is CSF.

C. Change the dressing using a compression bandage.
Changing the dressing might be necessary, but using a compression bandage without first identifying the nature of the fluid could be inappropriate and potentially harmful if the fluid is CSF.

D. Document the findings in the electronic medical record.
Documentation is important, but it is not the immediate action. The nurse needs to identify the nature of the fluid first.

Correct Answer is B

Explanation

A. Provide only distilled water. Providing only distilled water is not appropriate in this situation.
The client's weight gain and electrolyte imbalance indicate the need for careful monitoring and intervention, but restricting fluid intake to distilled water alone may not address the underlying issues adequately.
B. Document abdominal girth. Documenting abdominal girth is important to assess for signs of ascites, which can occur in hepatic failure. A sudden weight gain and elevated blood pressure may indicate fluid retention, and documenting abdominal girth can provide additional information about fluid accumulation in the abdomen.
C. Offer a high protein diet. While nutritional support is important for clients with hepatic failure, offering a high protein diet may not be appropriate if the client has an electrolyte imbalance. Protein intake should be balanced and monitored carefully to avoid exacerbating the imbalance.
D. Use a cushion when sitting. Using a cushion when sitting may be beneficial for comfort, but it does not directly address the identified issues of electrolyte imbalance, elevated blood pressure, and weight gain. The priority is to assess and address these concerns through appropriate
interventions such as documenting abdominal girth and addressing fluid retention.

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