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Which action should the nurse take to address suspicion of elder abuse?
- A. Privately interview the client about the injuries
- B. Document the injuries in detail, including size, location, and appearance
- C. Report the findings to the appropriate authorities, following facility protocol
- D. Take photographs of the injuries if permitted, as part of the documentation process
- E. Ensure that the client is not left alone with the suspected abuser during the interview or assessment
Correct Answer: C
Rationale: The correct action for the nurse to address suspicion of elder abuse is to report the findings to the appropriate authorities, following facility protocol (Choice C). This is because reporting to the authorities is crucial to protect the elderly individual from further harm and ensure that the necessary interventions are implemented.
- Choice A: Privately interviewing the client may jeopardize the safety of the elderly individual and may not be the most effective immediate action.
- Choice B: Documenting the injuries is important but reporting to authorities takes precedence in cases of suspected elder abuse.
- Choice D: Taking photographs of the injuries may be helpful for documentation but should not delay reporting to authorities.
- Choice E: Ensuring the client is not left alone with the suspected abuser is important but is not as urgent as reporting the abuse to the authorities.
In conclusion, reporting the findings to the appropriate authorities is the most critical and immediate action to address suspicion of elder abuse.
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Drag words from the choices below to fill in each blank.Nurse should anticipate a prescription for--------and-------
- A. skin traction
- B. surgical consultation
- C. pain medication
- D. limb immobilization
- E. antibiotics
- F. bed rest
Correct Answer: C,D
Rationale: Pain medication and limb immobilization are standard for managing fractures, reducing discomfort and promoting healing.
Which action should the nurse include in the plan?
- A. Minimize noise in the newborn's environment.
- B. Swaddle the newborn loosely to allow free movement.
- C. Position the newborn supine with legs extended.
- D. Encourage frequent handling and stimulation.
Correct Answer: A
Rationale: The correct answer is A because minimizing noise in the newborn's environment is crucial for promoting rest and reducing stress. Newborns are highly sensitive to loud noises, which can disrupt their sleep and affect their overall well-being. By creating a quiet environment, the nurse helps the newborn to feel secure and comfortable, promoting better sleep and overall development.
Choice B is incorrect because swaddling the newborn loosely may pose a suffocation risk and restrict movement, which is not recommended. Choice C is incorrect as positioning the newborn supine with legs extended may increase the risk of sudden infant death syndrome (SIDS). Choice D is also incorrect as encouraging frequent handling and stimulation can overwhelm the newborn's developing nervous system and lead to increased stress.
Which of the following sites should the nurse use?
- A. Axillary
- B. Rectal
- C. Oral
- D. Tympanic
Correct Answer: B
Rationale: The nurse should use the rectal site for temperature measurement as it provides the most accurate core body temperature reading. Rectal temperature closely reflects internal body temperature, making it the preferred site for assessing critically ill patients or infants who cannot cooperate for oral measurements. Axillary, oral, and tympanic sites may not accurately represent core body temperature due to external factors affecting the readings. Rectal temperature is the gold standard for accurate temperature measurement in certain clinical situations.
If the client develops a pneumothorax, which of the following assessment findings should the nurse expect?
- A. Stridor
- B. Pain on inhalation chest pain that worsens when you breathe or pleuritic pain
- C. Friction rub
- D. Bradycardia
Correct Answer: B
Rationale: The correct answer is B: Pain on inhalation chest pain that worsens when you breathe or pleuritic pain. A pneumothorax is the presence of air in the pleural space, causing lung collapse. When air enters this space, it creates pressure, leading to sharp chest pain that worsens with breathing (pleuritic pain). This occurs because the air-filled space prevents the lungs from expanding fully during inhalation, causing discomfort. Stridor (choice A) is a high-pitched sound indicating upper airway obstruction, not typically associated with a pneumothorax. Friction rub (choice C) indicates inflammation of the pleura, not specific to a pneumothorax. Bradycardia (choice D) is unlikely in pneumothorax, as it is more commonly associated with conditions affecting the heart rate.
A nurse is reviewing the client's electronic medical record. Which of the following findings require follow up?
- A. Potassium level
- B. Breath sounds
- C. WBC count
- D. Temperature
- E. Blood pressure
Correct Answer: C,D
Rationale: Decreased WBC count and elevated temperature suggest infection, requiring follow-up. Potassium levels remain within normal range, so no action is needed.