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Exhibits

Which intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.

Throw away soiled clothing.

Report findings to Adult Protective Services.

Develop a safety plan.

Take photographs to document the abuse or neglect.

Question the client in front of the suspected abuser.

Complete a comprehensive history.

Perform a thorough physical assessment.

Confront the abuser about concerning actions.

Answer and Explanation

Correct Answer : B,C,D,F,G

A. Throw away soiled clothing: This can destroy potential forensic evidence. Soiled items should be preserved in case they are needed for documentation or investigation.

B. Report findings to Adult Protective Services: Nurses are mandated reporters. If elder mistreatment is suspected, it must be reported to Adult Protective Services to initiate investigation and ensure the client’s safety.

C. Develop a safety plan: If abuse or neglect is suspected, the nurse should collaborate with the client (when possible) and the care team to develop a plan that ensures immediate and long-term safety.

D. Take photographs to document the abuse or neglect: Photographic documentation, with the client’s consent and per facility policy, provides visual evidence of physical injuries or poor living conditions, supporting investigation and care planning.

E. Question the client in front of the suspected abuser: This can place the client at greater risk and inhibit honest disclosure. All assessments regarding abuse should be done privately.

F. Complete a comprehensive history: Gathering a full medical and social history helps identify inconsistencies, patterns of neglect or injury, and risk factors. It supports accurate diagnosis and reporting.

G. Perform a thorough physical assessment: A full head-to-toe exam is essential to identify signs of injury, malnutrition, hygiene neglect, or other indicators of mistreatment.

H. Confront the abuser about concerning actions: Direct confrontation may escalate the situation and compromise the client's safety. The nurse should document objectively and follow legal reporting protocols.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. Monitor the client's current white blood cell count (WBC): While WBC can indicate infection, this is not an immediate concern at four hours post-op, where serosanguineous drainage is more likely related to surgical bleeding than infection.

B. Determine if the wound drainage device is functioning correctly: Excessive drainage could indicate a malfunctioning drain. Ensuring that the wound drainage system is properly working helps reduce fluid accumulation and prevents complications such as hematoma formation.

C. Withhold next scheduled dose of low molecular weight heparin: Anticoagulants are used to prevent deep vein thrombosis postoperatively and should not be withheld unless bleeding is active or confirmed excessive, which has not yet been determined.

D. Confirm that the continuous passive motion device is intact: While the device supports joint mobility, it is unrelated to assessing or managing wound drainage, which is the priority concern in this situation.

A. Carrots. B. Beets. C. Low fat yogurt. D. Mixed berries.

Correct Answer is C

Explanation

A. Carrots: Carrots are a good source of beta-carotene and promote eye health, but they are not high in calcium or vitamin D, which are critical nutrients for bone health in postmenopausal women.

B. Beets: While beets support cardiovascular health and offer fiber and folate, they do not provide significant amounts of calcium or vitamin D needed to prevent osteoporosis.

C. Low fat yogurt: Low fat yogurt is rich in calcium and often fortified with vitamin D, both of which are essential for maintaining bone mass and reducing the risk of osteoporosis after menopause.

D. Mixed berries: Berries are high in antioxidants and support immune health, but they lack the calcium and vitamin D that are most important for postmenopausal women’s bone health.

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Exhibits Which intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

The nurse is providing a nutrition class to a group of postmenopausal clients. Which food should the nurse emphasize to this group?

Correct Answer is C

Explanation

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Exhibits

Which intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.