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."

Answer and Explanation

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.

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

Explanation

A. Pneumococcal vaccine:

The pneumococcal vaccine is recommended for older adults to protect against Streptococcus pneumoniae, a common cause of pneumonia and other invasive diseases. Individuals over 65 years of age are at increased risk for pneumococcal infections, making this vaccine essential for their health.

B. Influenza vaccine:

The influenza vaccine is recommended annually for older adults, as they are at high risk for severe complications from influenza due to age-related immune system decline. Preventing influenza reduces the risk of secondary infections, such as pneumonia.

C. COVID-19 vaccine:

COVID-19 vaccines are strongly recommended for older adults because they are at higher risk for severe illness and complications from COVID-19. Staying up to date with booster doses further reduces the risk of hospitalization and death.

D. HIB vaccine:

The Haemophilus influenzae type b (HIB) vaccine is not routinely recommended for adults unless they have specific medical conditions, such as asplenia or immunodeficiencies. This vaccine is primarily targeted for infants and young children.

E. Rotavirus vaccine:

The rotavirus vaccine is not recommended for adults. It is specifically designed to prevent rotavirus gastroenteritis in infants and young children. There is no clinical indication for its use in the older adult population.

A. Have the client swish with commercial mouthwash before therapy. B. Place fresh flowers in the clients room C. Tell the client to expect dark stools following chemotherapy. D. Administer an antiemetic prior to the procedure.

Correct Answer is D

Explanation

A) Have the client swish with commercial mouthwash before therapy:
Some commercial mouthwashes contain alcohol, which can be irritating to the mucous membranes, especially in clients undergoing chemotherapy. Chemotherapy can cause mucositis or stomatitis, making the oral cavity more sensitive, so alcohol-based mouthwashes should be avoided

B) Place fresh flowers in the client's room:
Fresh flowers are not recommended in the rooms of clients undergoing chemotherapy because they can introduce bacteria into the environment, which is particularly concerning for clients with weakened immune systems due to chemotherapy. Chemotherapy suppresses the immune system, increasing the risk of infection.

C) Tell the client to expect dark stools following chemotherapy:
Chemotherapy can cause a variety of gastrointestinal side effects, but dark stools are not a typical or expected side effect. Dark stools may indicate gastrointestinal bleeding, which requires immediate attention.

D) Administer an antiemetic prior to the procedure:
Chemotherapy commonly causes nausea and vomiting, and preemptive administration of antiemetic medications can help prevent these symptoms. The nurse should follow the healthcare provider's orders and administer antiemetics as prescribed, which can significantly improve the client's comfort and adherence to the treatment plan.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

A nurse is preparing a client who is to receive chemotherapy for treatment of ovarian cancer. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

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