When child, elder, or vulnerable adult abuse or neglect is disclosed, what is the nurse's responsibility?
Report the abuse according to facility policy.
Consider a referral to social services.
Meet with the patient's family.
Contact the primary care provider.
The Correct Answer is A
A) Report the abuse according to facility policy: The nurse has a legal and ethical responsibility to report suspected or disclosed abuse or neglect immediately, following the facility's protocols and state laws. This ensures that appropriate action is taken to protect the vulnerable individual and provides necessary interventions.
B) Consider a referral to social services: While this may be part of the broader care plan, the immediate priority is to report the abuse. Social services can be involved after the initial reporting to ensure that the appropriate support systems are put in place for the individual.
C) Meet with the patient's family: Meeting with the family may be relevant in some cases, but it is not the nurse's primary responsibility upon disclosure of abuse. Involving family members can sometimes complicate situations, especially if they are involved in the abuse.
D) Contact the primary care provider: While informing the primary care provider may be necessary as part of ongoing care, the urgent responsibility is to report the abuse to the proper authorities. The healthcare provider can then be informed as part of the care coordination after the initial report is made.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is A
Explanation
A) Crepitus: This is the correct term to document the grating sound heard when a joint is moved. Crepitus can indicate issues such as the presence of air in the joint, cartilage degeneration, or other pathologies. Using this specific term provides clarity to the medical record and helps other healthcare providers understand the nature of the joint's condition.
B) Positive joint sounds: This phrase is less specific and does not adequately describe the type of sound noted during the assessment. It may also lead to ambiguity, as it lacks the medical precision that crepitus provides.
C) Grating and popping: While this description conveys what the nurse observed, it is not a standardized medical term. Precise documentation is essential in medical records, and using non-standard language can lead to confusion.
D) Crackles: Typically associated with respiratory assessments, crackles refer to sounds heard in the lungs and are not applicable to joint examinations. Therefore, this term would be inappropriate for documenting findings related to joint movement.
Correct Answer is C
Explanation
A) Obtain an order for a catheter: While catheterization can help manage elimination needs, it is generally considered a more invasive approach and is not the first line of action unless absolutely necessary. The goal should be to maintain the client’s dignity and encourage as much independence as safely possible.
B) Allow the client to walk independently: Given that the Romberg test is positive, indicating potential balance issues, allowing the client to walk independently could increase the risk of falls and injury. Safety is a primary concern in this situation.
C) Obtain a bedside commode: This intervention is appropriate as it provides a safe and accessible option for the client to meet their elimination needs without the need to navigate to a bathroom, which may be challenging given their balance issues. A bedside commode allows for easier access while minimizing the risk of falls.
D) Limit fluid intake: Limiting fluid intake is not a safe or effective way to address elimination needs and could lead to dehydration and other complications. Encouraging appropriate fluid intake is important for overall health, provided the client can manage elimination safely.