Nursing Elites

1. The nurse is assessing an elder whom the nurse suspects is being physically abused. The most important question for the nurse to ask is:

• A. "How much money do you keep around the house?"?
• B. "Who provides your physical care?"?
• C. "How close does your nearest relative live?"?
• D. "What form of transportation do you use?"?

Correct answer: B

Rationale: The most important question for the nurse to ask when suspecting elder abuse is 'Who provides your physical care?' This question is crucial as the primary caregiver, who is often the abuser in cases of elder abuse, lives with the client. Research has shown that spouses and adult children are the most common abusers. By inquiring about the provider of physical care, the nurse can assess the potential abuser's proximity to the elder. Choices A, C, and D are less pertinent to identifying the primary caregiver, who is more likely to be the abuser.

2. A woman seeks assistance because she recently remembered childhood sexual abuse. The nurse should include which of the following goals for this client?

• A. prosecuting the perpetrator
• B. managing symptoms of anxiety and fear
• C. determining if the memories are real
• D. collaborating with the client's story

Correct answer: B

Rationale: The correct answer is 'managing symptoms of anxiety and fear.' When a client remembers childhood sexual abuse, the nurse's primary goal should be to help the client cope with the emotional distress and symptoms such as anxiety and fear. Prosecuting the perpetrator is not within the nurse's scope of practice and is a legal matter. Determining if the memories are real is not the nurse's role; the focus should be on providing support and care. Collaborating with the client's story is vague and does not address the immediate emotional needs of the client.

3. Due to a high census, it has been necessary for a number of clients to be transferred to other units within the hospital. Which client should be transferred to the postpartum unit?

• A. A 66-year-old female with gastroenteritis
• B. A 40-year-old female with a hysterectomy
• C. A 27-year-old male with severe depression
• D. A 28-year-old male with ulcerative colitis

Correct answer: B

Rationale: The best client to transfer to the postpartum unit is the 40-year-old female with a hysterectomy. The nurses on the postpartum unit will be knowledgeable about postoperative care and can manage any complications related to the surgery. Choices A and D would be more appropriately cared for on a medical-surgical unit due to their conditions. Choice C should be transferred to a psychiatric unit for specialized care related to severe depression.

4. A client sitting alone and talking to voices is observed by a nurse. When asked, the client reports he is 'talking to the voices.' The nurse's next action should be:

• A. touching the client to help him return to reality
• B. leaving the client alone until reality returns
• C. asking the client to describe what is happening
• D. telling the client there are no voices

Correct answer: C

Rationale: When a client reports talking to voices, it can indicate the presence of hallucinations. Asking the client to describe what is happening is a crucial step as it helps the nurse understand the nature of the hallucinations and provides reassurance to the client. Touching the client without consent is inappropriate and can be distressing. Leaving the client alone may not address the underlying issue, and telling the client there are no voices denies their experience and can lead to mistrust.

5. During a well-baby check of a 6-month-old infant, the nurse notes abrasions and petechiae of the palate. The nurse should:

• A. inquire about the possibility of sexual abuse.
• B. ask about the types of foods the child is eating.
• C. request to see the type of bottle used for feedings.
• D. question the parent about objects the child plays with.

Correct answer: A

Rationale: The correct answer is to inquire about the possibility of sexual abuse. Injuries to the soft palate such as bruising, abrasions, and petechiae can be signs of sexual abuse in infants. While oral sex may not leave significant physical evidence, these findings should raise suspicion. Option A is correct as it focuses on addressing potential abuse. Options B, C, and D are incorrect because the child's diet, the type of bottle used for feedings, and play objects are not likely related to the observed injuries. The presence of oral injuries suggests considering sexual abuse rather than other factors.

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