Patient Data

Exhibits

The nurse reviews the findings in the history and physical.

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The nurse recognizes that

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and

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are findings consistent with elder mistreatment.

Rationale:

A. Complete a comprehensive history: Gathering a full medical and psychosocial history helps the nurse identify patterns of neglect, dependency, or caregiver control. It also provides critical context about baseline function and recent changes in the client’s condition.

B. Confront the abuser about concerning actions: Directly confronting the suspected abuser may increase the risk of retaliation against the client and compromise the safety of both client and provider. It may also hinder legal investigations if not handled properly.

C. Develop a safety plan: Developing a safety plan is essential when elder mistreatment is suspected. It outlines strategies and resources to protect the client from further harm, including steps to ensure physical and emotional safety within or outside the home.

D. Perform a thorough physical assessment: A comprehensive physical exam allows the nurse to document injuries, skin breakdown, hygiene status, and other signs of neglect. Objective findings support the identification and substantiation of potential mistreatment.

E. Report findings to Adult Protective Services: Mandatory reporting is required in suspected elder abuse cases. Reporting to APS initiates an investigation and can mobilize protective services and interventions, including caregiver support or removal if needed.

F. Question the client in front of the suspected abuser: Interviewing the client in the presence of the suspected abuser can lead to incomplete or falsified responses due to fear, coercion, or shame. Private questioning ensures more honest communication.

G. Throw away soiled clothing: Soiled clothing may contain forensic evidence such as bodily fluids, skin cells, or wound drainage. Disposing of it could compromise the legal investigation or documentation of neglect.

H. Take photographs to document the abuse or neglect: Photographic evidence provides visual documentation that supports clinical findings. This can strengthen the case when authorities investigate, and helps track the healing or progression of injuries over time.

Rationale:

A. Self-description of pain: Pain assessment is important in general care but is not directly related to assessing for obstructive sleep apnea. OSAS is more concerned with sleep patterns, airway obstruction, and associated risk factors like weight and anatomy rather than pain.

B. Body mass index: BMI is a key factor in determining OSAS risk. Obesity, especially central adiposity, contributes to pharyngeal narrowing and increased airway resistance during sleep. A high BMI is one of the most significant predictors of obstructive sleep apnea.

C. Level of consciousness: While decreased alertness can result from sleep deprivation caused by OSAS, it is a non-specific finding. It may support further evaluation but does not directly assess the risk for OSAS or its underlying causes.

D. Breath sounds: Although breath sounds can reveal lung pathology, they typically remain normal in OSAS unless another respiratory condition is present. They are not the most important assessment for evaluating sleep-disordered breathing risk.