Scenario

A nurse is conducting an initial home health assessment for an 84-year-old female client in her daughter’s home. The client was recently discharged after hospitalization for an exacerbation of heart failure (HF).

Exhibits
Choose the most likely options for the missing information in the statements by selecting from the lists of options provided. This client is exhibiting signs of
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. he nurse is a mandated reporter and therefore must report the elder mistreatment to
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Answer and Explanation

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

Rationale for correct answers

Neglect: The client’s condition and living situation indicate neglect. The client is frail, has poor hygiene, unkempt hair, dry skin, and visible pressure injuries. The daughter, who is the primary caregiver, admits to being overwhelmed and neglecting the client’s needs, such as hygiene and repositioning. Neglect is defined as the failure to provide necessary care, assistance, and supervision to a dependent individual, leading to harm or potential harm.

Adult Protective Services: As a mandated reporter, the nurse must report the signs of elder mistreatment to Adult Protective Services (APS). APS is responsible for investigating reports of abuse, neglect, and exploitation of elderly or disabled adults. Reporting to APS ensures that the client receives the necessary intervention and support to address the neglect and improve her quality of life.

Rationale for incorrect answers

Abandonment: Abandonment refers to deserting an elderly person, leaving them without the necessary care and support. In this case, the client has not been deserted; her daughter is present and attempting to provide care, although she is overwhelmed and neglectful. Therefore, abandonment is not the correct answer.

Physical abuse: Physical abuse involves the intentional use of physical force that results in bodily injury, pain, or impairment. There is no evidence of physical abuse in this case. The client’s condition is due to neglect, not physical harm inflicted by another person.

Self-neglect: Self-neglect occurs when an individual fails to meet their own basic needs, such as personal hygiene, nutrition, or medical care. In this scenario, the client is dependent on her daughter for care and unable to provide for herself due to limited mobility. The neglect is not self-imposed but rather due to the caregiver's inability to meet her needs.

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Correct Answer is A

Explanation

Choice A rationale

Asking the client to describe the pain is the most effective way to assess the quality of pain. This approach allows the client to provide specific details about their pain experience, including the type, intensity, and characteristics, which are essential for accurate pain management.

Choice B rationale

Identifying effective pain relief measures is important but does not directly assess the quality of pain. This step is more focused on treatment rather than the initial assessment of pain quality.

Choice C rationale

Observing body language and movement can provide additional information about the pain but is not as reliable as directly asking the client. Nonverbal cues should supplement, not replace, the client's verbal report.

Choice D rationale

Providing a numeric pain scale helps quantify the intensity of pain but does not assess the quality. Quality assessment requires a descriptive approach to understand the nature of the pain fully.

Correct Answer is ["0.75"]

Explanation

Step 1 is 0.1875 mg ÷ 0.25 mg/mL Step 2 is 0.75 mL Final answer: 0.75 mL.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with metastatic bone cancer is requesting pain medication. Which approach should the nurse use to assess the quality of the client's pain?

Correct Answer is A

Explanation

Correct Answer is ["0.75"]

Explanation

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