Patient Data
Which intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.
Complete a comprehensive history.
Confront the abuser about concerning actions.
Develop a safety plan.
Perform a thorough physical assessment.
Report findings to Adult Protective Services.
Question the client in front of the suspected abuser.
Throw away soiled clothing.
Take photographs to document the abuse or neglect.
Correct Answer : A,C,D,E,H
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Teach parents about poison prevention in young children: While this is an important long-term intervention, it does not address the immediate concern of replacing a potentially lost therapeutic dose of the antidote. Teaching should occur after the child’s safety is ensured.
B. Lavage activated charcoal before giving acetylcysteine dose: Activated charcoal may reduce acetylcysteine’s effectiveness when administered together. Gastric lavage is not routinely indicated if the child is alert and beyond the immediate ingestion window, and is not a substitute for re-dosing the antidote.
C. If dose is vomited within 1 hour of administration, repeat that oral dose: Re-administering N-acetylcysteine within one hour of vomiting ensures the child receives an effective therapeutic dose. Prompt re-dosing is crucial in preventing hepatic damage.
D. Obtain blood samples to monitor liver function: Liver function tests are part of ongoing monitoring but do not address the acute need to ensure the antidote is absorbed. Blood work is secondary to ensuring that the child receives the full therapeutic dose.
Correct Answer is ["B","D","E"]
Explanation
Rationale:
A. Ask the client if someone brought her to the clinic: This may be useful in a general assessment but is not directly relevant to the client's urinary symptoms, bruising, or potential abuse concerns. It does not guide immediate care.
B. Review list of daily medications for aspirin or other anticoagulants: Ecchymoses may indicate increased bleeding risk, especially in older adults on aspirin or anticoagulants. Reviewing medications helps determine if bruising is medication-related or from trauma.
C. Question her if she previously or currently uses any illicit drugs: There’s no clinical indicator pointing toward drug use. This line of questioning may be inappropriate or unnecessary unless other findings support it.
D. Inquire if she is being emotionally or physically abused: Unexplained bruising, especially in older adults, can signal possible abuse. The nurse should screen for abuse sensitively and privately.
E. Determine number of sexual partners she has had recently: Given her report of sexual activity and urinary burning, assessing recent sexual history helps guide further STI screening and urinary symptom evaluation.
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