The nurse notes old and new ecchymotic areas on an older adult client's arms and buttocks upon admission. The client tells the nurse in confidence that her family members frequently hit her. Which statement should the nurse use in response?
‘’I have a legal obligation to report this type of abuse."
"Let's get these treated, and I will maintain confidence."
"Let's talk about ways to prevent someone from hitting you"
"If this happens again, you must call the emergency department."
The Correct Answer is A
A) "I have a legal obligation to report this type of abuse."
The nurse has a legal and ethical obligation to report suspected abuse or neglect, especially in vulnerable populations such as older adults. In many jurisdictions, mandatory reporting laws require healthcare professionals to report suspected abuse to the appropriate authorities (e.g., Adult Protective Services, law enforcement) to ensure the safety of the client.
B) "Let's get these treated, and I will maintain confidence."
While it is essential to provide care for the physical injuries, the nurse cannot promise to maintain confidence in cases of suspected abuse. Confidentiality can be breached in situations where a legal obligation to report abuse exists. Failing to report suspected abuse could jeopardize the client's safety and place the nurse at risk of legal consequences.
C) "Let's talk about ways to prevent someone from hitting you."
This might seem compassionate, but it does not address the legal obligation to report the abuse. The priority should be to ensure the client's safety by reporting the situation to the appropriate authorities. Focusing on preventative measures without reporting the abuse first may imply that the responsibility lies with the client to prevent the abuse, rather than ensuring that the perpetrator is held accountable and the client is protected from harm.
D) "If this happens again, you must call the emergency department."
While advising the client to call the emergency department is a reasonable step in cases of immediate harm, it does not address the current abuse or the need for immediate intervention. The nurse's primary responsibility is to report the abuse to the proper authorities and ensure the client's safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A"]
Explanation
A) Unilateral facial drooping:
Unilateral facial drooping is the hallmark sign of Bell's palsy, a condition that results from inflammation of the facial nerve (cranial nerve VII). This inflammation causes muscle weakness or paralysis on one side of the face, leading to drooping of the mouth, eyelid, and other facial features on the affected side. The facial drooping may worsen with smiling, closing the eyes, or other facial expressions, making this a key finding in Bell’s palsy.
B) Unilateral arm weakness:
Unilateral arm weakness is not typically associated with Bell's palsy, which specifically affects the facial muscles due to nerve damage. While weakness can occur in other parts of the body due to neurological conditions, it is not a characteristic symptom of Bell’s palsy, which is primarily a cranial nerve issue. Therefore, arm weakness would prompt consideration of other potential neurological causes.
C) Alopecia:
Alopecia, or hair loss, is not a common symptom of Bell's palsy. Although it can be seen in many different conditions, it is not typically linked with Bell's palsy, which is a disorder of the facial nerve. Bell’s palsy affects facial muscles, leading to symptoms like drooping or inability to close the eye, but it does not directly cause hair loss.
D) Difficulty swallowing:
Difficulty swallowing (dysphagia) can occur in Bell's palsy, especially if the facial nerve affects the ability to control the muscles involved in swallowing. This may lead to difficulty with chewing, swallowing, or speaking clearly. While not always severe, dysphagia is a potential complication due to the involvement of the facial nerve, which controls facial muscles essential for these functions.
E) Inability to close the affected eye:
The inability to close the affected eye is a common symptom of Bell's palsy due to paralysis of the orbicularis oculi muscle, which is controlled by the facial nerve. This can lead to dryness or irritation of the eye and a risk for corneal damage if the eye is not properly closed or protected. This inability to close the eye is one of the hallmark features of Bell's palsy.
Correct Answer is B
Explanation
A. 250 mg:
This represents the amount of levodopa in the tablet, not carbidopa. Sinemet contains two active ingredients: carbidopa (25 mg) and levodopa (250 mg), as shown on the label.
B. 25 mg:
This is the correct answer, as the label indicates that each tablet contains 25 mg of carbidopa. Carbidopa is combined with levodopa to improve its effectiveness and reduce side effects like nausea.
C. 5 mg:
This is not accurate; the label clearly states that the carbidopa dose is 25 mg per tablet.
D. 200 mg:
This does not correspond to the dose of carbidopa or levodopa in this medication. The label specifies 25 mg of carbidopa and 250 mg of levodopa.
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