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Patient Data

Exhibits

New data is reviewed.

Choose the most likely options for the information missing from the statements by selecting from the lists of options provided.

This client is exhibiting signs of

. The nurse is a mandated reporter and therefore must report the elder mistreatment to .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Rationale for Correct Choices

  • Neglect: The client presents with signs of poor hygiene, untreated pressure injuries, confinement to bed without a clear medical reason, and a reduction in social interaction and autonomy. These factors collectively indicate neglect, which is the failure of a caregiver to meet the basic physical, emotional, and social needs of a dependent adult.
  • Adult Protective Services: Adult Protective Services is the appropriate authority to report suspected abuse or neglect of older adults living in private homes. As a mandated reporter, the nurse is legally required to report suspected elder mistreatment to APS to initiate an investigation and protect the client.

Rationale for Incorrect Choices

  • Sexual abuse: There are no indicators such as bruising in private areas, fear of the caregiver, or behavioral cues that might suggest sexual trauma. The case centers on physical neglect, not sexual abuse.
  • Financial exploitation: The client has not reported any unauthorized financial activity, and there is no evidence of the caregiver misusing or controlling the client’s finances. This makes financial exploitation an unlikely concern.
  • Long Term Care Program: This agency oversees long-term care facilities like nursing homes. Since the client resides in a private home, the situation falls outside the jurisdiction of this program.
  • State Department of Health: The Department of Health primarily monitors healthcare providers and facilities, not private caregiving situations. Therefore, it is not the correct agency to report suspected elder abuse in this context.


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Related Questions

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

Explanation

Rationale for Correct Choices:

  • Frequent neurologic assessments: Frequent neurological checks are crucial during and after tPA administration to detect early signs of complications, particularly worsening neurological status, which may indicate intracranial bleeding. These assessments help ensure prompt intervention if deterioration occurs.
  • Intracerebral hemorrhage: Intracerebral hemorrhage is the most serious and well-known risk of thrombolytic therapy. Monitoring for signs such as sudden headache, changes in consciousness, or worsening neurological symptoms is essential to detect this life-threatening complication early.

Rationale for Incorrect Choices:

  • Continuous blood pressure monitoring: Although blood pressure control is important during tPA administration, continuous monitoring is not always required. Frequent checks (e.g., every 15 minutes) are typically sufficient unless there is an acute hypertensive crisis or rapid changes in neurological status.
  • Hourly intake and output measuring: While intake and output may be monitored in ICU settings, this is not the priority during tPA administration. It does not help in detecting the most immediate and severe risk associated with thrombolytics.
  • Pulmonary embolism: tPA is used to treat embolic events, not likely to cause them. Pulmonary embolism is not a known complication of thrombolytic therapy in ischemic stroke cases and would not be the primary concern during administration.
  • Deep vein thrombosis: DVT is a potential complication from immobility in stroke patients, but not from tPA use. Monitoring for DVT is important during hospitalization but is not the priority during or immediately after tPA infusion.

Correct Answer is A

Explanation

Rationale:
A. "Chest physiotherapy should be performed twice a day before a meal.” Chest physiotherapy helps clear mucus from the lungs and is most effective when done before meals to prevent vomiting and optimize lung function and oxygenation.

B. "Administer a cough suppressant every 8 hours." Cough suppressants are generally avoided in cystic fibrosis because coughing is necessary to mobilize and expel thick secretions from the airways.

C. "Energy should be conserved by scheduling minimally strenuous activities." Physical activity is encouraged to enhance lung expansion and mucus clearance. Energy conservation is not the priority unless the child is acutely ill.

D. "Maintain supplemental oxygen at 4 to 6 L/minute." High-flow oxygen is not routinely used and may suppress respiratory drive. Oxygen is used with caution and only as prescribed in advanced disease or during exacerbations.

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