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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Free Nursing Study Resources

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

Explanation

The correct answers are Choices A, C, and D.

Choice A rationale: Encouraging the client to increase physical activity and engage with peers is appropriate as it helps prevent deconditioning, improves cardiovascular health, and promotes mental well-being. Physical activity can also improve muscle strength, mobility, and overall quality of life.

Choice B rationale: Suggesting the client remain in bed to avoid unnecessary exertion is incorrect. Prolonged bed rest can lead to muscle atrophy, pressure injuries, and decreased cardiovascular function. The client should be encouraged to mobilize as tolerated to maintain functional abilities.

Choice C rationale: Teaching the caregiver how to monitor for signs of infection in pressure injuries is crucial because the client has stage II pressure injuries that need careful monitoring and management to prevent complications such as infection. Education on signs of infection, proper wound care, and prevention strategies is essential.

Choice D rationale: Assisting the client in using the restroom to avoid incontinence is appropriate as it respects the client's preference for toileting, reduces the risk of skin breakdown, and promotes dignity. Helping the client maintain continence and proper hygiene is important for comfort and overall health.

A. Assess the serum potassium level every 4 hours. B. Evaluate glucose levels before and after meals. C. Monitor and document strict intake and output. D. Obtain a 12-lead electrocardiogram daily.

Correct Answer is A

Explanation

Choice A rationale

Assessing serum potassium levels every 4 hours is essential for clients receiving insulin to treat hyperkalemia. Insulin promotes the uptake of potassium into cells, potentially leading to hypokalemia. Frequent monitoring ensures prompt detection of abnormal potassium levels, enabling timely intervention.

Choice B rationale

Although glucose monitoring is important, it is not the priority. Insulin administration affects potassium levels more significantly in this scenario, and glucose level fluctuations are typically less life-threatening than potassium imbalances.

Choice C rationale

Monitoring intake and output is standard practice for managing clients with electrolyte imbalances. However, it does not directly address the primary concern of potassium level fluctuations caused by insulin administration.

Choice D rationale

A daily 12-lead electrocardiogram may provide useful information on the cardiac effects of electrolyte imbalances but is less immediate in detecting rapid potassium changes than frequent serum potassium measurements.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

The healthcare provider prescribes a 5% dextrose injection with 20 units of regular insulin for a client with a serum potassium level of 6.0 mEq/L (6.0 mmol/L) and glucose level of 180 mg/dL (10.0 mmol/L). Which evaluation is most important for the nurse to include in this client's plan of care?

Correct Answer is A

Explanation

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