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Patient Data

Exhibits

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.

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Rationale:
A. Aspiration: Aspiration is typically a concern in clients with impaired swallowing, reduced consciousness, or neurologic disorders. Elevated parathyroid hormone (PTH) does not directly affect swallowing function or airway protection.

B. Falls: Elevated PTH levels cause hypercalcemia, which can lead to muscle weakness, fatigue, confusion, and bone demineralization. These effects increase the client’s risk for falls and fractures, making fall prevention a key safety priority.

C. Suicide: While chronic illness can impact mood, elevated PTH levels are not directly associated with suicidal ideation. Psychiatric monitoring is important but not the primary safety focus in this case.

D. Hypothermia: PTH imbalance does not significantly affect thermoregulation. Hypothermia is not a typical complication of elevated PTH levels and does not require focused preventive measures in this scenario.

A. Evaluate client teaching through return demonstration. B. Establish blood pressure parameters for client monitoring. C. Evaluate a staff member providing wound care. D. Measure the client's body weight each morning.

Correct Answer is D

Explanation

Rationale:
A. Evaluate client teaching through return demonstration: Evaluation of client teaching is a higher-level assessment requiring clinical judgment, which is within the RN's scope of practice. Practical nurses can reinforce teaching, but they do not evaluate comprehension independently.

B. Establish blood pressure parameters for client monitoring: Setting parameters for vital sign monitoring involves critical thinking and interpretation of the care plan or medical orders. This is the responsibility of the RN and should not be assigned to a PN.

C. Evaluate a staff member providing wound care: Staff evaluations, including assessing competency in procedures, are leadership responsibilities typically held by RNs or supervisors, not PNs. Delegating this to a PN may compromise quality assurance.

D. Measure the client's body weight each morning: This is a stable and routine task involving the collection of objective data. PNs are competent to perform and document such tasks, especially in long-term care where trends in weight are often monitored.

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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

The nurse is caring for a client with elevated parathyroid hormone levels. Which safety precaution should the nurse include in the plan of care?

Correct Answer is B

Explanation

The charge nurse in an extended care facility is organizing unit activities for the day. Which action may be safely delegated to the practical nurse (PN)?

Correct Answer is D

Explanation

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Patient Data

Exhibits

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