Answer to Question 1
ANS: B
In this situation, each facility will have a policy designed for assessing competence. The nurse should bring these concerns to an interdisciplinary care team meeting. There may be physiologic reasons for the client to be temporarily too confused or incompetent to give consent. If an acute condition is ruled out, the staff should follow the legal procedure and policies in their facility and state for determining competence. The key is to bring the concerns forward. Calling Adult Protective Services is not appropriate at this time. Signing the consent should wait until competence is determined unless it is an emergency, in which case the next of kin can sign if there are grave doubts as to the client's ability to provide consent.
Answer to Question 2
ANS: D
These findings are suspicious for abuse. Health care providers are mandatory reporters for suspected abuse. The nurse should notify social work, case management, or whomever is designated in policies. That person can then assess the situation further. If the police need to be notified, that is the person who will notify them. Adult Protective Services is notified in the community setting.
Older adults may grieve intensely over the loss of a person or situation that has been a part of the
The surgical nurse assists the client into the correct position
A Corner of the General Massage Section of an Army Hospital. A Practice of Physiotherapy by Sampson, ...
Measuring the client’s height with a platform scale
Testing the client’s ability to feel vibrations, the toe
Client’s view with visual field loss