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A nurse is admitting an older adult client who was transferring from another facility. The nurse notes pressure ulcers on the clients Coccyx and abrasions around both wrists which of the following actions should the nurse take to address suspicion of elder abuse?
Which actions 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: A,B,C,D,E
Rationale: The correct actions to address suspicion of elder abuse are A, B, C, D, and E.
A: Privately interviewing the client allows for open communication and confidentiality.
B: Documenting injuries in detail provides objective evidence for reporting and potential legal action.
C: Reporting findings to authorities is crucial to protect the elder and comply with legal obligations.
D: Taking photographs, if permitted, supports documentation and investigation.
E: Ensuring the client is not left alone with the suspected abuser protects the client during the assessment. Each action plays a crucial role in addressing elder abuse comprehensively.
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A nurse is providing teaching to a client who is 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching?
- A. Bleeding gums
- B. Faintness upon rising
- C. Swelling of the face
- D. Urinary frequency
Correct Answer: C
Rationale: The correct answer is C: Swelling of the face. This finding could be indicative of preeclampsia, a serious condition in pregnancy characterized by high blood pressure and organ damage. It is crucial to report this to the provider promptly to prevent complications. Bleeding gums (A) are common due to hormonal changes and increased blood flow, not typically a cause for concern. Faintness upon rising (B) is common in pregnancy due to low blood pressure but usually not a significant issue unless severe. Urinary frequency (D) is normal in pregnancy due to the growing uterus pressing on the bladder.
A nurse is assessing the fontanels of 8-month-old infant.
which of the following findings should the nurse recognize as an expected finding?
- A. The anterior fontanel is open
- B. The posterior fontanel is open
- C. The anterior fontanel is sunken
- D. The anterior fontanel is bulging
Correct Answer: A
Rationale: The correct answer is A: The anterior fontanel is open. This is an expected finding in infants as the anterior fontanel typically remains open until around 18-24 months of age, allowing for the growth and expansion of the skull bones. It is a normal part of development and closure indicates maturation. The posterior fontanel closes earlier than the anterior fontanel, so option B is incorrect. Option C, sunken anterior fontanel, indicates dehydration, while option D, bulging anterior fontanel, is a sign of increased intracranial pressure, both of which are abnormal findings.
A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit.
Which of the following statements should the nurse include in the hand-off report?
- A. The estimated blood loss was 250 mL.
- B. The client has a good appetite and ate well before surgery.
- C. The client's family visited during the recovery period.
- D. The client's call light is within reach.
Correct Answer: A
Rationale: The correct answer is A: The estimated blood loss was 250 mL. This statement is important for the receiving nurse to know as it provides crucial information about the client's condition post-surgery. It helps in monitoring for signs of hemorrhage or other complications. The other choices (B, C, D) are not essential for the hand-off report as they do not directly impact the client's immediate care or safety. Choice B is subjective and not a clinical observation. Choice C is about the client's family, which is not pertinent to the client's medical status. Choice D is a general safety measure and not specific to the client's condition.
A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother.
Which of the following responses should the nurse make?
- A. I can give you information about respite care if you are interested.
- B. You should try to sleep more so you can take better care of your mother.
- C. Caring for a loved one at the end of life is very rewarding.
- D. It's important to stay strong for your mother during this time.
Correct Answer: A
Rationale: The correct answer is A because it acknowledges the caregiver's potential interest in respite care, which can provide them with much-needed rest and support. This response shows empathy and offers a helpful solution. Choice B is incorrect as it oversimplifies the situation and places undue pressure on the caregiver. Choice C is incorrect as it may invalidate the caregiver's struggles and emotions, as caregiving can be overwhelming and challenging. Choice D is incorrect as it emphasizes the importance of strength without addressing the caregiver's need for support and self-care.
The charge nurse on a medical surgical unit is assisting with the emergency response plan following an external disaster in the community.
In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge?
- A. A client who was one day postoperative following a vertebroplasty.
- B. A client receiving IV antibiotics for pneumonia with a fever of 101°F(38.3°C).
- C. A client who had a transient ischemic attack(TIA) 12 hours ago and is awaiting further evaluation.
- D. A client with uncontrolled atrial fibrillation requiring continuous cardiac monitoring.
Correct Answer: A
Rationale: The correct answer is A. The client one day postoperative following a vertebroplasty can be recommended for early discharge as this procedure is typically short-stay and does not require extended monitoring. The client is likely stable and can continue recovery at home.
Choice B is incorrect because a client with pneumonia and a fever of 101°F requires continued IV antibiotics and monitoring to ensure resolution of infection and fever reduction.
Choice C is incorrect as a client with a recent TIA requires further evaluation and monitoring to prevent recurrent strokes and assess for potential complications.
Choice D is incorrect because a client with uncontrolled atrial fibrillation requiring continuous cardiac monitoring should not be discharged early as they need close monitoring and management to prevent complications like stroke or heart failure.