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Patient Data

Exhibits

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

Report findings to Adult Protective Services.

Perform a thorough physical assessment.

Confront the abuser about concerning actions.

Develop a safety plan.

Question the client in front of the suspected abuser.

Take photographs to document the abuse or neglect.

Throw away soiled clothing.

Complete a comprehensive history.

Answer and Explanation

Correct Answer : A,B,D,F,H

A. Report findings to Adult Protective Services: Reporting to Adult Protective Services (APS) is essential when elder mistreatment is suspected. APS can investigate the situation further and take appropriate action to ensure the safety and well-being of the elder.

B. Perform a thorough physical assessment: Conducting a thorough physical assessment helps to identify any signs of abuse or neglect, such as pressure injuries, poor hygiene, or physical injuries. It provides necessary information to support the suspicion of mistreatment.

C. Confront the abuser about concerning actions: Confronting the abuser directly can be dangerous for the client and may interfere with the investigation. It is best to report concerns to appropriate authorities who can handle the situation professionally.

D. Develop a safety plan: Developing a safety plan is crucial to protect the client from immediate harm. This plan includes steps to ensure the client’s safety and well-being while further actions are being taken.

E. Question the client in front of the suspected abuser: Questioning the client in front of the suspected abuser could put the client at further risk of harm. It is important to ensure the client’s safety and privacy when gathering information.

F. Take photographs to document the abuse or neglect: Documenting findings through photographs can provide evidence of abuse or neglect, which is important for reporting and investigation purposes. This documentation should be done with caution and respect for privacy.

G. Throw away soiled clothing: Disposing of soiled clothing does not address the underlying issue of mistreatment and may destroy potential evidence. Soiled clothing should be documented and handled appropriately.

H. Complete a comprehensive history: Completing a comprehensive history helps to gather detailed information about the client’s living conditions, care needs, and any changes in their behavior or condition that might indicate mistreatment.

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Correct Answer is B

Explanation

A. Increased fatigue is a common side effect of many medications and illnesses but is not as immediately concerning.

B. Watery diarrhea can indicate a serious side effect such as Clostridium difficile-associated diarrhea, which requires prompt medical attention.

C. Nausea and headache are common side effects but are generally not urgent.

D. Yellow-tinged sputum can indicate infection but is not as critical as the potential for a serious gastrointestinal issue.

A. Note the presence of an auscultatory gap. B. Reposition the stethoscope over the brachial artery. C. Continue with the blood pressure assessment. D. Reinflate the cuff to a higher number. E. None F. None

Correct Answer is C

Explanation

A.An auscultatory gap is a period of silence that occurs between systolic and diastolic sounds (often seen in hypertensive patients). You cannot confirm a gap exists until you have completed the entire deflation and noted if sounds disappear and then reappear.

B. Since the nurse already heard a Korotkoff sound, the stethoscope is correctly placed over the brachial artery. Moving it now would interrupt the reading.

C. When performing manual blood pressure measurement, the transition from silence to the first rhythmic tapping sound indicates the systolic blood pressure (Phase I of Korotkoff sounds). Hearing silence followed by a clear sound after the valve has been released is the expected progression of the procedure.

D.Reinflating the cuff immediately on the same arm can cause venous congestion, leading to an inaccurate (falsely high) diastolic reading. If a reading must be repeated, the nurse should deflate the cuff completely and wait 1 to 2 minutes before trying again.

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Patient Data 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

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

Correct Answer is C

Explanation

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Patient Data

Exhibits

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