The home health nurse assesses an older adult woman and observes possible signs of abuse. Which resource best guides the nurse's decision regarding reporting these suspicions?
State law.
American Nurse Association (ANA) Code of Ethics.
Nurse Practice Act.
The facility’s nursing procedure manual.
The Correct Answer is A
Choice A reason: State law governs mandatory reporting requirements for suspected abuse. It provides legal guidance on when and how to report, and protects the nurse from liability when reporting in good faith. Compliance with state law is essential in safeguarding vulnerable populations.
Choice B reason: The ANA Code of Ethics outlines professional responsibilities and moral obligations but does not provide legal mandates or procedures for reporting abuse.
Choice C reason: The Nurse Practice Act defines scope of practice and licensure requirements but does not specifically address abuse reporting protocols.
Choice D reason: Facility procedures may offer internal guidance but cannot override legal obligations. They are secondary to state law in determining the nurse’s duty to report.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: Rechecking vital signs in 30 minutes delays critical intervention. The client is showing signs of a potentially life-threatening postoperative complication such as an anastomotic leak or internal hernia, which can rapidly deteriorate. Delaying action could result in worsening sepsis or bowel ischemia.
Choice B reason: While assessing oxygen saturation is part of a comprehensive evaluation, it does not address the underlying cause of the symptoms. The client’s fever, tachycardia, hypotension, and referred shoulder pain suggest peritoneal irritation and possible sepsis, which require immediate transport and surgical evaluation.
Choice C reason: Instructing the client to drive themselves is unsafe. The client is hemodynamically unstable and may deteriorate en route. Driving could delay care and increase risk of injury or death.
Choice D reason: Transporting the client via ambulance ensures rapid access to emergency care and allows for monitoring during transit. The symptoms are consistent with a surgical emergency such as an anastomotic leak or internal hernia, which require prompt imaging and possible surgical intervention.
Correct Answer is A
Explanation
Choice A reason: Primary prevention focuses on preventing disease before it occurs. Educating farm workers on how to avoid pesticide exposure addresses a major environmental hazard in agricultural settings and helps prevent acute and chronic illnesses such as respiratory conditions, neurological symptoms, and certain cancers. This action is proactive and aligns with the goals of primary prevention.
Choice B reason: Managing low back pain is a tertiary prevention strategy, aimed at reducing complications and improving quality of life after the condition has developed. It does not prevent the initial onset of disease or injury.
Choice C reason: Tuberculosis screening is a secondary prevention measure. It identifies disease early to initiate treatment, but it does not prevent initial exposure or infection.
Choice D reason: Teaching first aid for heat exhaustion is a secondary or tertiary intervention. It helps manage symptoms after exposure to heat stress but does not prevent the condition from occurring.
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