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 D

Explanation

A. "What happened to you in the past to make you so desperate?" may be seen as judgmental and may not be as helpful in the immediate crisis. It assumes a specific cause for the desperation and might not address the current feelings or circumstances that are contributing to the suicidal thoughts.

B. "What will you accomplish by taking your life?"This question may be perceived as confrontational or dismissive of the client's feelings. It might not provide a clear understanding of the immediate risk or plan.

C. "Why do you feel depressed enough to end your life?" is a direct question that may put pressure on the client and might not be as effective in exploring their thoughts and feelings. It assumes a direct link between depression and suicidal thoughts without allowing for a more nuanced exploration.

D. "How will you carry out your plan?"This question is crucial because it helps assess the seriousness of the client's intent and the immediacy of the risk. Understanding the specifics of the plan can help the nurse evaluate the level of danger and take appropriate actions to ensure the client's safety.

A. A client requests an appointment to discuss their depression B. A client who states that they are stopping their medication C. A client who states they have been sleeping 12 hr a day D. A client who is giving away their possessions

Correct Answer is D

Explanation

A. Requesting an appointment to discuss depression is an indication that the client is seeking help, which is a positive step. It does not necessarily indicate an immediate risk of suicide.

B. Stating that they are stopping their medication raises concerns about treatment compliance, but it does not provide a clear indication of suicidal intent. It is important to assess the reasons for discontinuing medication and address any concerns.

C. Sleeping 12 hours a day can be a symptom of depression, but it does not necessarily indicate an immediate risk of suicide. It is crucial to assess the client's overall mental health and functioning.

D. A client who is giving away their possessions.
Giving away possessions can be a warning sign of suicidal intent. This behavior may indicate that the individual is preparing for the possibility of not needing those belongings in the future. It is crucial for the nurse to assess and intervene promptly if a client is exhibiting signs of suicidality.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is threatening to commit suicide, which of the following questions should the nurse ask?

Correct Answer is D

Explanation

A nurse is caring for a group of clients at a mental health facility. The nurse should identify that which of the following clients is exhibiting a warning sign of suicide?

Correct Answer is D

Explanation

A nurse is caring for a client who has been brought to the emergency department and is experiencing acute fentanyl toxicity. The nurse should expect to observe which of the following adverse effects in this client?

A nurse is caring for a client who is prescribed alprazolam, a benzodiazepine for managing severe manifestations of anxiety. Which of the following should the nurse prepare to discuss with the client?

A nurse is caring for a group of clients in a mental health facility. Which of the following clients recommend the physician or nurse practioner see first?

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 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?

A nurse observes a client sitting alone in her room crying. As the nurse approaches her, the client states, "I'm feeling sad. I don't want to talk now." Which of the following responses should the nurse make?

A nurse is caring for a client who reports a state of increasing anxiety and the inability to sleep and concentrate. Which of the following is an appropriate response by the nurse?

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