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 D

Explanation

Choice A rationale: While psychological assessment is important, it is not the primary focus for assessing outcomes in this case. The client's physical health conditions and the impact on her daily living and functional ability are more directly relevant.

Choice B rationale: Financial security is not the primary concern in this context. The primary focus is on the client's health and ability to perform activities of daily living (ADLs), which is addressed by evaluating functional improvement.

Choice C rationale: Quality of life is a broad concept that includes many aspects such as emotional, social, and physical well-being. While it is relevant, the primary outcome measure in this context is the client's functional improvement related to her health conditions and ability to manage ADLs.

Choice D rationale: Functional improvement is the correct focus for evaluating the client's outcomes. This includes her ability to perform activities of daily living (ADLs) and manage her health conditions. The nurse should assess how well the client can maintain or improve her functional abilities with the additional care provided.

A. Oxygen saturation of 56% B. Crackles heard in the right lung C. pH of 7.21 D. Tracheal deviation to the right

Correct Answer is ["A","D"]

Explanation

Choice A rationale: Oxygen saturation of 56% is critically low and indicates severe hypoxemia, which requires immediate intervention to improve oxygenation and prevent life-threatening complications.

Choice D rationale: Tracheal deviation to the right suggests a possible tension pneumothorax, which is a medical emergency. It requires immediate attention to relieve the pressure on the affected lung and restore normal breathing.

Choice B rationale: Crackles heard in the right lung indicate fluid or atelectasis but are not immediately life-threatening compared to the other findings.

Choice C rationale: A pH of 7.21 indicates acidemia and respiratory acidosis but is a secondary concern compared to the immediate need to address the client's hypoxemia and potential tension pneumothorax.

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is caring for a 59-year-old male client in the intermediate care unit. Exhibits Which of the following findings requires the nurse's immediate attention?

Correct Answer is ["A","D"]

Explanation

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