Special Pops - Cp 10 (Violence and elder mistreatment)

An older patient lives alone and has not bathed or changed clothing for several days. An investigator for adult protective services visits and determines this patient is experiencing which type of elder mistreatment? 1. Self-neglect 2. Physical abuse 3. Psychological abuse 4. Financial exploitation

ANS: 1 Rationale 1: Self-neglect occurs when mentally competent patients engage in behaviors that threaten their own safety and well-being. Failure to maintain proper hygiene practices falls into this category of elder mis- treatment.Reference: Page 234 Rationale 2: Physical abuse is the intentional infliction of physical injury or pain. Reference: Page 234 Rationale 3: Psychological abuse involves the infliction of anguish or emotional abuse. Reference: Page 234 Rationale 4: Financial exploitation is taking advantage of an older person for monetary or personal benefit. Reference: Page 234

Which patients seen by a nurse working in the emergency department identify a situation that suggests a case of elder mistreatment? 1. An 86-year-old patient who has three dime-size burned areas on the upper inner thigh 2. A 77-year-old patient who fell at home after tripping over the dog and broke an arm about 30 minutes earlier 3. A 73-year-old patient with a history of gastric ulcers who is found to be anemic after vomiting blood 3 hours earlier 4. An 85-year-old patient who has several small areas of bruising on the back of the hands and is taking med- ication for platelets and coagulation

ANS: 1 Rationale 1: The patient who has skin burns suggestive of cigarette burns in an area normally covered by clothing is suggestive of abuse.Reference: Page 237 Rationale 2: A patient with a broken bone that is consistent with an injury event and seeks medical attention promptly is not generally suspect for elder abuse.Reference: Page 237 Rationale 3: The patient with a positive history of gastric ulcers and active bleeding would be expected to have anemia.Reference: Page 237 Rationale 4: Bruising is common in patients taking medication that affects the blood, who have thin skin, and in the hands, which is an area that is easily bumped.Reference: Page 237

The adult daughter of an older patient is researching viable skilled facilities to have the patient admitted for long-term care needs. This research has not revealed much information about institutional abuse. Why is this information not readily available to the daughter? SATA 1. Residents may fear retribution. 2. Managers fear adverse publicity. 3. Staff members fear losing their jobs. 4. Family members fear having to find a new agency for the patient. 5. Billing department members fear not getting paid for services provided to patients.

ANS: 1, 2, 3, 4 Rationale 1: A federal report revealed large delays in the reporting of incidents of elder mistreatment in nurs- ing homes. One reason for this delay is that residents may fear retribution if they report the abuse. Reference: Page 236 Rationale 2: A federal report revealed large delays in the reporting of incidents of elder mistreatment in nurs- ing homes. One reason for this delay is that the managers of the facilities may fear adverse publicity about the abuse.Reference: Page 236 Rationale 3: A federal report revealed large delays in the reporting of incidents of elder mistreatment in nurs- ing homes. One reason for this delay is that staff members may fear losing their jobs if they report abuse of residents.Reference: Page 236 Rationale 4: A federal report revealed large delays in the reporting of incidents of elder mistreatment in nurs- ing homes. One reason for this delay is that families may fear having to find a new agency for the patient. Reference: Page 236 Rationale 5: A federal report revealed large delays in the reporting of incidents of elder mistreatment in nurs- ing homes. Billing or payment issues are not reasons why incidents of elder abuse in nursing homes are not being reported.Reference: Page 236

In which situations is institutional mistreatment of older patients most likely to occur? SATA 1. Staff burnout 2. Staffing shortage 3. Patient aggressiveness 4. Inadequate staff training 5. Family members frequently visit

ANS: 1, 2, 3, 4 Rationale 1: Staff burnout may be a precipitating factor in the mistreatment of nursing home residents. Reference: Page 236 Rationale 2: Staffing shortages may be a precipitating factor in the mistreatment of nursing home residents. Reference: Page 236 Rationale 3: Patient aggressiveness was found to be a predictor of physical and psychological abuse by staff members.Reference: Page 236 Rationale 4: Inadequate staff training may be a precipitating factor in the mistreatment of nursing home resi- dents.Reference: Page 236 Rationale 5: Frequent family visits are not identified as being a precipitating factor in the mistreatment of nursing home residents.Reference: Page 236

An older patient who just celebrated an 85th birthday comes into the emergency department with a fractured arm and bruises over the chest and back. The nurse suspects the patient is a victim of physical abuse. Which individuals will the nurse specifically assess the patient as being the abuser? SATA 1. Spouse 2. Nephew 3. Granddaughter 4. Next door neighbor 5. Adult daughter caregiver

ANS: 1, 2, 3, 5 Rationale 1: Spouses account for 11.3% of abuse cases. Reference: Page 233 Rationale 2: Family members account for 21.5% of abuse cases. Reference: Page 233 Rationale 3: Family members account for 21.5% of abuse cases. Reference: Page 233 Rationale 4: Next door neighbors are not identified as individuals who cause abuse cases. Reference: Page 233 Rationale 5: The typical abuser is an adult child, accounting for 32.6% of abuse cases. Reference: Page 233

An older patient has been brought into the emergency department with injuries caused by suspected physical abuse. Which tools could the nurse use to assess this patient's injuries? SATA 1. Indicators of abuse screen 2. AMA assessment protocol 3. Adult protective services report 4. Brief abuse screen for the elderly 5. Hwalek-Sengstock elder abuse screening test

ANS: 1, 2, 4, 5 Rationale 1: The indicators of abuse screen is a 29-item set of indicators for use by social service agency prac- titioners to identify elder mistreatment.Reference: Page 238 Rationale 2: The AMA assessment protocol is a checklist used if abuse is suspected. Reference: Page 238 Rationale 3: Adult protective services do not use a specific format. Intake forms are used to document calls of suspected elder mistreatment from public hotlines and state agencies.Reference: Page 238 Rationale 4: The brief abuse screen for the elderly asks five standard questions that focus on abuse. Reference: Page 238 Rationale 5: The Hwalek-Sengstock elder abuse screening test is one 15-item assessment screen for detecting suspected elder abuse and neglect.Reference: Page 238

The daughter of an older patient who is a resident of a nursing home suspects the patient is a victim of abuse. What should the nurse suggest that the daughter do about this situation? SATA 1. Visit the facility at varied times. 2. Do nothing until evidence is obtained. 3. Realize that the patient can be confused. 4. Participate in the resident's council. 5. Actively participate in care plan meetings.

ANS: 1, 4, 5 Rationale 1: For the older adult living in long-term care facilities, the California Advocates for Nursing Home Reform recommend that family should visit the facility at varied times.Reference: Page 241 Rationale 2: The nurse should not recommend that the daughter do nothing about the situation until evidence is obtained. The older patient could be drastically harmed.Reference: Page 241 Rationale 3: There is no evidence that the older patient is confused. The nurse should not make this recom- mendation to the daughter.Reference: Page 241 Rationale 4: For the older adult living in long-term care facilities, the California Advocates for Nursing Home Reform recommend that the family participate in the resident's council.Reference: Page 241 Rationale 5: For the older adult living in long-term care facilities, the California Advocates for Nursing Home Reform recommend that the family actively participate in care plan meetings for the older patient. Reference: Page 241

An older patient is being abused by family members in the home and asks about adult protective services. What should the nurse explain about these services? 1. They punish persons who abuse the elderly. 2. They provide services to protect older people who may be abused or neglected. 3. They provide a way to permanently keep the older patient separated from the abuser. 4. They place older patients who cannot adequately care for themselves in nursing homes.

ANS: 2 Rationale 1: Adult protective services (APS) programs are social services organized to protect vulnerable older adults who may be abused, neglected, or exploited. APS do not punish persons who abuse the elderly. Reference: Page 234 Rationale 2: Adult protective services (APS) programs are social services organized to protect vulnerable older adults who may be abused, neglected, or exploited.Reference: Page 234 Rationale 3: Adult protective services (APS) programs are social services organized to protect vulnerable older adults who may be abused, neglected, or exploited. APS do not permanently keep the older patient separated from the abuser. Reference: Page 234 Rationale 4: Adult protective services (APS) programs are social services organized to protect vulnerable older adults who may be abused, neglected, or exploited. APS do not place older patients into nursing homes. Reference: Page 234

The nurse is caring for a patient who has been the victim of elder abuse by her son. According to the situational violence theory of elder mistreatment, which situation would have occurred? 1. The son is unemployed. 2. The care of the patient has overwhelmed the son. 3. The patient sent the son to live at boarding school. 4. The son witnessed several young boys being beat up in the neighborhood.

ANS: 2 Rationale 1: Employment status of the son is not a part of the situational violence theory of elder mistreat- ment. Employment may play a role in the characteristics of the abuser.Reference: Page 233 Rationale 2: The situational violence theory suggests that elder mistreatment is thought to be a result of the caregiver becoming overwhelmed by the care the patient requires.Reference: Page 233 Rationale 3: The situational violence theory does not address how children are raised and educated. Reference: Page 233 Rationale 4: The situational violence theory does not address a situation of violence that the son may have witnessed while growing up. This could be explained through the learning theory of violence.Reference: Page 233

What will the nurse keep in mind when documenting the suspected abuse of an older patient? 1. Photo documentation is not usually included as part of the documentation. 2. Documentation should include objective data of the older patient's reaction when the suspected abuser is present. 3. It is important to include the nurse's personal opinion of the suspected abuser and the nurse's prior experi- ence in similar cases. 4. The details of the documentation should not be reported to the adult protective services; it is important that they come to an independent conclusion about the issue of abuse.

ANS: 2 Rationale 1: Photographic documentation is especially helpful in cases where there is observable evidence. Reference: Page 242 Rationale 2: Older adults who appear fearful when in the presence of a suspected abuser will need careful as- sessment as this may be a warning sign of mistreatment. Physical indicators of elder mistreatment that are clearly described will assist interdisciplinary members with diagnosis as well as with planning goals of patient care. Reference: Page 242 Rationale 3: The nurse should present the facts objectively and not include personal conclusions or other inci- dents not related to the case.Reference: Page 242 Rationale 4: The nurse's findings that led to the suspicion of abuse should be shared in the report to adult protective services.Reference: Page 242

The nurse is caring for an older patient who has been the victim of elder abuse by an adult son. According to the transgenerational violence theory of elder mistreatment, which situation would have occurred with the patient? 1. The son is an alcoholic. 2. The care of the patient has overwhelmed the son. 3. The patient was abusive to the son when he was a child. 4. As a child, the son witnessed the father beating the mother.

ANS: 3 Rationale 1: The son being an alcohol is an example of the psychopathology theory for abuse. Reference: Page 233 Rationale 2: The care of the patient overwhelming the son is an example of the psychopathology theory for abuse.Reference: Page 233 Rationale 3: The transgenerational violence theory suggests that elder mistreatment is thought to be part of the family violence continuum. It begins with child abuse and ends with elder abuse.Reference: Page 233 Rationale 4: The son witnessing the father beating the mother is an example of the learned theory of abuse. Reference: Page 233

An older patient is accompanied to a physician's office visit with an adult daughter who walks with an assistive device. The older patient is hard of hearing, has osteoarthritis, and has difficulty completing activities of daily living. Which nursing diagnosis would the nurse identify as being the priority at this time? 1. Social isolation 2. Caregiver role strain 3. Ineffective protection 4. Situational low self-esteem

ANS: 2 Rationale 1: The diagnosis of social isolation is not a priority since there is no evidence that the older patient is isolated.Reference: Page 241 Rationale 2: Caregiver role strain is the priority since the daughter walks with an assistive device and needs to help the older patient who is hard of hearing, has osteoarthritis, and has difficulty completing activities of daily living. The daughter may become stressed with having to help the older patient as well as herself with care needs. Reference: Page 241 Rationale 3: There is no evidence to support that the older patient is at risk for ineffective protection. Reference: Page 241 Rationale 4: There is no evidence to support that the older patient is experiencing situational low self-esteem. Reference: Page 241

An emergency room nurse is caring for an older patient brought in by a neighbor. The neighbor states that the patient lives with a son who "drinks a lot." What does the nurse assess that suggests elder neglect? SATA 1. Thick, yellow fingernails 2. Pressure ulcer on the sacrum 3. Dry, cracked lips and tongue 4. Small skin tears to the right elbow 5. Cracked, dry skin on the lower legs bilaterally

ANS: 2, 3 Rationale 1: Thick, yellow fingernails could be an expected finding in an older patient and not indicative of ne- glect.Reference: Page 234 Rationale 2: A pressure ulcer on the sacrum is a manifestation of caregiver neglect. Reference: Page 234 Rationale 3: Common signs and symptoms of neglect include dehydration, which would be manifested as dry, cracked lips and tongue.Reference: Page 234 Rationale 4: Small skin tears to the right elbow do not necessarily indicate caregiver neglect and could have occurred during routine activities in the home.Reference: Page 234 Rationale 5: Cracked dry skin on both lower legs does not necessarily indicate caregiver neglect. This could be an expected finding in an older patient.Reference: Page 234

The home healthcare nurse is preparing an educational program for other healthcare providers regarding elder abuse. What information should the nurse include? SATA 1. The typical abuser is the spouse. 2. The typical abuser is the adult child. 3. The typical elder who is abused is a woman. 4. The majority of abuse occurs in the home setting. 5. The majority of abuse occurs in the long-term care setting.

ANS: 2, 3, 4 Rationale 1: Spouses account for only 11.3% of abuse. Reference: Page 233 Rationale 2: Adult children account for 32.6% of abuse. Reference: Page 233 Rationale 3: The typical older person who is abused is a Caucasian woman. Reference: Page 233 Rationale 4: The vast majority of abuse and neglect occurs in the domestic setting. Reference: Page 233 Rationale 5: Although institutional abuse can occur, the vast majority of abuse occurs in the home setting. Reference: Page 233

During a home visit, the nurse is concerned that an older patient is experiencing caregiver neglect. What did the nurse assess in this patient? SATA 1. Agitation 2. Listlessness 3. Dry, cracked skin 4. Bruises on both arms 5. Skin irritation on both inner thighs

ANS: 2, 3, 5 Rationale 1: Agitation is a manifestation of psychological or emotional abuse. Reference: Page 234 Rationale 2: Listlessness is a manifestation of caregiver neglect. Reference: Page 234 Rationale 3: Dry, cracked skin could indicate dehydration, which is a manifestation of caregiver neglect. Reference: Page 234 Rationale 4: Bruises on both arms is a manifestation of physical abuse. Reference: Page 234 Rationale 5: Skin irritation on both inner thighs could indicate urine burns, which is a manifestation of caregiv- er neglect.Reference: Page 234

An older patient tearfully tells a nurse that she must buy the neighbor's groceries or the neighbor will not drive the patient to the store. The nurse recognizes this situation as being which type of elder mistreatment? 1. Abuse 2. Neglect 3. Exploitation 4. Abandonment

ANS: 3 Rationale 1: Abuse is any action or inaction harming or endangering the welfare of an older adult. Reference: Page 234 Rationale 2: Neglect involves failure to provide adequate care or services for an older adult. Reference: Page 234 Rationale 3: Elder mistreatment by exploitation involves the abuser taking advantage of the older person for monetary or personal benefit. This is the case in which the older patient is being coerced to buy the neighbor's groceries.Reference: Page 234 Rationale 4: Abandonment is the desertion or willful forsaking of an older person. Reference: Page 234

The home care nurse is preparing to visit an older female patient who lives in her son's home. Prior to the visit, which risk factors for elder abuse will the nurse review? 1. Male gender 2. Hispanic race 3. Impaired cognitive status 4. High socioeconomic status

ANS: 3 Rationale 1: Females are at a higher risk for elder abuse than males. Reference: Page 236 Rationale 2: Those of the Caucasian race are at a higher risk for elder abuse than other races. Reference: Page 236 Rationale 3: Cognitive impairment is a risk factor for elder abuse. Reference: Page 236 Rationale 4: Poverty, and not a high socioeconomic status, is a risk factor for elder abuse. Reference: Page 236

The nurse is concerned that an older patient is at risk for abuse because the patient lives with an adult son who is an alcoholic. Which theory of elder mistreatment is this nurse basing this concern for the patient? 1. Isolation 2. Situational 3. Psychopathology 4. Transgenerational

ANS: 3 Rationale 1: The isolation theory of elder abuse believes that mistreatment is prompted by a dwindling social network.Reference: Page 233 Rationale 2: The situational theory of elder abuse believes that as the care burden increases, the caregiver's capacity to meet the needs of the older adult may be inadequate.Reference: Page 233 Rationale 3: In the psychopathological theory of elder abuse, caregivers who have preexisting conditions may have impaired capacity to give appropriate care, such as a caregiver with alcohol dependency may not be able to exercise appropriate judgment in caregiving of an older adult, which can ultimately lead to abuse or neglect. Reference: Page 233 Rationale 4: In the transgenerational theory of elder abuse, elder mistreatment is thought to be a part of a family violence continuum, which may begin with child abuse and end with elder mistreatment.Reference: Page 233

The nurse is concerned that specific families in a community are at increased risk for transgenerational vio- lence. Which family situation exemplifies the transgenerational theory of violence? 1. Family with a daughter who abuses alcohol 2. Family with a daughter who has severe arthritis and finds it increasingly difficult to deal with her forgetful, frail mother 3. Family with a son who, as a teenager and young adult, had serious arguments with his parents, who were emotionally abusive to him 4. Family with a daughter who is working two jobs with significant debts and cares for her father, who is be- coming more confused and dependent

ANS: 3 Rationale 1: The theory of psychopathology of the abuser refers to caregivers who have preexisting conditions that impair their abilities to provide proper care, as in the case of an adult child who has an ongoing alcohol abuse problem.Reference: Page 233 Rationale 2: The theory of psychopathology of the abuser refers to caregivers who have preexisting conditions that impair their abilities to provide proper care, as in the case of an adult child with severe arthritis. Reference: Page 233 Rationale 3: The theory of transgenerational violence involves a continuum of family violence. A child grows up in a home where a contentious family relationship and some form of abuse is the norm. The child who was abused grows up and later becomes aggressive and abusive to the elderly parent.Reference: Page 233 Rationale 4: Situational theory or caregiver stress involves care burdens that outweigh the caregiver's abilities to deliver care. Examples of caregiver stress are severe financial or time constraints paired with the older adult requirements for more physical care or supervision.Reference: Page 233

An older patient is accompanied by an adult daughter who is the patient's primary caregiver for a routine clinic visit. While in the waiting room, the adult daughter is observed sitting quietly and not talking with the patient. During the examination, what should the nurse assess the adult daughter for? SATA 1. Employment 2. Physical status 3. Caregiver stress 4. Substance abuse 5. History of psychopathology

ANS: 3, 4, 5 Rationale 1: Caregivers of older adults should be assessed at each primary care visit for caregiver stress, sub- stance abuse, and a history of psychopathology. Employment is not something that needs to be assessed in the caregivers of older adults.Reference: Page 236 Rationale 2: Caregivers of older adults should be assessed at each primary care visit for caregiver stress, sub- stance abuse, and a history of psychopathology. Physical status is not something that needs to be assessed in the caregivers of older adults.Reference: Page 236 Rationale 3: Caregivers of older adults should be assessed at each primary care visit for caregiver stress. Reference: Page 236 Rationale 4: Caregivers of older adults should be assessed at each primary care visit for substance abuse. Reference: Page 236 Rationale 5: Caregivers of older adults should be assessed at each primary care visit for a history of psy- chopathology.Reference: Page 236

The nurse suspects that an older patient has been physically abused. What must be included in the medical workup for this patient? 1. Pelvic examination 2. Toxicological screening 3. Complete blood count and blood chemistries 4. Complete visual examination with clothing removed

ANS: 4 Rationale 1: A pelvic examination is indicated for suspected sexual abuse. Reference: Page 241 Rationale 2: Toxicological screening is indicated for suspected drug abuse. Reference: Page 241 Rationale 3: Complete blood count and blood chemistries would be indicated if concerns included neglect re- flected by malnutrition and dehydration.Reference: Page 241 Rationale 4: If you suspect elder mistreatment or abuse, a complete visual examination of the older person without clothing is necessary. Abusers may strike where clothing hides the resulting bruises. You can protect privacy by assessing the older person's body one area at a time from head to toe.Reference: Page 241

The home care nurse asks an older patient's caregiver to complete a questionnaire regarding caregiver strain. The caregiver states, "You are here to see my mom. Why do you need information about me?" Which is the most appropriate response by the nurse? 1. "We fill out this paperwork for all caregivers." 2. "We need to make sure you don't abuse your mother." 3. "It's just something that the insurance companies make us fill out." 4. "We need information about how you are dealing with caring for your mother. We don't want you to become overwhelmed."

ANS: 4 Rationale 1: It has been documented that fewer older adults report mistreatment by family members, which may be a protective act. Caregivers of older adults should be assessed at each primary care visit for caregiver stress, substance abuse, and a history of psychopathology. The Modified Caregiver Strain Index has been rec- ommended by the Hartford Institute of Geriatric Nursing as the best practice in the nursing care of older adults. This instrument is a valid and reliable screening tool and can identify caregivers in need of support. The nurse should not state that the reason is to complete paperwork. Reference: Page 236 Rationale 2: It has been documented that fewer older adults report mistreatment by family members, which may be a protective act. Caregivers of older adults should be assessed at each primary care visit for caregiver stress, substance abuse, and a history of psychopathology. The Modified Caregiver Strain Index has been rec- ommended by the Hartford Institute of Geriatric Nursing as the best practice in the nursing care of older adults. This instrument is a valid and reliable screening tool and can identify caregivers in need of support. Re- sponding that it ensures that the caregiver is not abusing the patient is not a therapeutic response. Reference: Page 236 Rationale 3: It has been documented that fewer older adults report mistreatment by family members, which may be a protective act. Caregivers of older adults should be assessed at each primary care visit for caregiver stress, substance abuse, and a history of psychopathology. The Modified Caregiver Strain Index has been rec- ommended by the Hartford Institute of Geriatric Nursing as the best practice in the nursing care of older adults. This instrument is a valid and reliable screening tool and can identify caregivers in need of supp

A visitor to a long-term care institution witnesses an attendant scolding a patient with dementia about being incontinent. What type of abuse is the visitor witnessing? 1. Neglect 2. Exploitation 3. Caregiver burnout 4. Psychological abuse

ANS: 4 Rationale 1: Neglect occurs when there is failure to meet the older person's needs necessary for physical and emotional well-being.Reference: Page 234 Rationale 2: Exploitation involves taking advantage of an older person for monetary or personal benefit. Reference: Page 234 Rationale 3: Caregiver burnout is not a type of abuse but could cause a caregiver to abuse an older patient. Reference: Page 234 Rationale 4: A caregiver who scolds and ridicules a patient who is unable to care for him- or herself is commit- ting psychological abuse by inflicting anguish and psychological pain.Reference: Page 234

Which older patient is at greatest risk for mistreatment in the home? 1. An active older patient with well-controlled diabetes who lives alone 2. A healthy older patient who is retired from owning a business and lives with an adult son 3. An older patient with a history of coronary bypass surgery, is active, and lives with the spouse 4. An older patient with severe osteoarthritis and macular degeneration who lives with a single daughter who has an adult son with cerebral palsy

ANS: 4 Rationale 1: Risk factors for elder mistreatment include being female, over the age of 75, having a dependent functional status, having a poor social network, poverty, minority, cognitive impairment, and having less than an 8th grade education. An active older patient who has a chronic illness and lives alone is not at risk for mis- treatment in the home. Reference: Page 236 Rationale 2: A healthy older patient who is retired from owning a business and living with an adult son is not at risk for mistreatment in the home.Reference: Page 236 Rationale 3: Risk factors for elder mistreatment include being female, over the age of 75, having a dependent functional status, having a poor social network, poverty, minority, cognitive impairment, and having less than an 8th grade education. An older patient with a history of coronary bypass surgery and lives with the spouse is not at risk for mistreatment in the home. Reference: Page 236 Rationale 4: Risk factors for elder mistreatment include being female, over the age of 75, having a dependent functional status, having a poor social network, poverty, minority, cognitive impairment, and having less than an 8th grade education. An older patient with severe osteoarthritis and macular degeneration who lives with a single daughter who has a son with a health problem is at the greatest risk for mistreatment in the home. Reference: Page 236

An older patient with a black eye is diagnosed with a broken arm that is reported as being caused by falling on a shovel while clearing snow from a walkway. Why should the nurse suspect physical abuse with this patient? 1. The patient is confused. 2. The patient is 65 years old. 3. The patient is African American. 4. The patient's testing results are inconsistent with the history given.

ANS: 4 Rationale 1: There is no evidence to suggest that the patient is confused. Reference: Page 237 Rationale 2: One characteristic of older abuse victims is an age over 75 years. Reference: Page 237 Rationale 3: One characteristic of older abuse victims is Caucasian race. Reference: Page 237 Rationale 4: One sign of elder mistreatment includes diagnostic testing results inconsistent with the history given.Reference: Page 237