A nurse is conducting a home health visit for an older adult client who lives with family members. The nurse notices that the client has multiple unusual bruises, and, based on several other factors, the nurse suspects that the client has been physically abused. Which of the following actions should the nurse take first?

Check the bruises at the next visit to the client's home.

Follow the agency's guidelines for reporting suspected abuse.

Institute more frequent visits to the client's home.

Arrange referral for family therapy to deal with home stressors.

Answer and Explanation

The Correct Answer is B

A. Checking the bruises at the next visit may delay necessary intervention. If abuse is suspected, immediate action, such as reporting, is essential to protect the client.

B. Following the agency's guidelines for reporting suspected abuse is the priority when abuse is suspected. Reporting abuse to the appropriate authorities, such as adult protective services or law enforcement, is crucial to ensure the safety and well-being of the older adult.

C. Instituting more frequent visits to the client's home might be part of a safety plan, but it should not be the first action. Reporting suspected abuse is the priority to involve the appropriate authorities.

D. Arranging a referral for family therapy is not the first step in suspected elder abuse. Safety and protection of the older adult take precedence. Once the immediate safety concerns are addressed, additional interventions, such as family therapy, may be considered.

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Correct Answer is B

Explanation

A. Dental caries is not a specific complication commonly associated with heroin use. Dental issues may result from other substances or lifestyle factors.

B. Perforation of the nasal septum is a complication associated with the intranasal use of heroin. Chronic snorting or sniffing of heroin can damage the nasal septum, leading to a perforation.

C. Permanent effects on short-term memory loss are more commonly associated with the use of substances like cannabis or certain hallucinogens. Heroin use is not typically linked to permanent effects on short-term memory.

D. Pancreatitis is not a commonly reported complication of heroin use. Pancreatitis is more commonly associated with alcohol use disorder and gallstone-related issues.

A. "A single dose of diazepam is unlikely to cause side effects." B. "Grapefruit juice inactivates this medication." C. "Diazepam can cause drowsiness." D. Avoid foods that contain tyramine"

Correct Answer is C

Explanation

A. "A single dose of diazepam is unlikely to cause side effects" is not accurate. Diazepam, like any medication, can have side effects even with a single dose. Common side effects include drowsiness, dizziness, and muscle weakness.

B. "Grapefruit juice inactivates this medication" is not specifically true for diazepam. However, grapefruit juice can interact with certain medications by inhibiting their metabolism in the liver, leading to increased levels of the drug in the bloodstream. It's essential to check for specific drug interactions, but this statement is not a key consideration for diazepam.

C. "Diazepam can cause drowsiness" is an important piece of information to include because diazepam is a benzodiazepine medication that can have sedative effects. Alerting the client to the potential for drowsiness is crucial to prevent any safety issues, such as falls or accidents.

D. "Avoid foods that contain tyramine" is not relevant to diazepam. Tyramine is associated with certain foods and can be a concern with medications called monoamine oxidase inhibitors (MAOIs). Diazepam is not an MAOI, so this advice does not apply to its use.

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Naxlex Comprehensive Predictor Exams

A nurse is assisting in the development of a community education course about the physical complications related to substance use disorder. Which of the following complications should the nurse include in the discussion about heroin use?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client who takes diazepam (Valium). Which of the following information should the nurse include?

Correct Answer is C

Explanation

A nurse is reviewing the admission laboratory values for a client who has a history of bulimia nervosa. Which of the following findings is the nurse's priority?

A nurse is caring for a client who has paranoid schizophrenia and a new prescription for risperidone. The client asks the nurse what the s is supposed to do. Which of the following responses should the nurse make?

A nurse is reinforcing teaching with a client who is scheduled to receive electroconvulsive therapy (ECT). Which of the following statements should the nurse include in the teaching?

A nurse is collecting data from a client who has major depressive disorder (MDD). Which of the following findings should the nurse expect?

A nurse is talking with a client who has schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things." Which of the following responses by the nurse is appropriate?

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