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 {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

The nurse should first address the client's cardiac status followed by the client's Nutritional status

Explanation:

Cardiac status: Potassium levels are critically low, which can significantly impact cardiac function.
Nutritional status: The client has multiple electrolyte imbalances, which could be related to nutrition or absorption issues.

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

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

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 schizophrenia. Exhibits Select the "3" findings that should indicate to the nurse the client is experiencing negative symptoms related to their schizophrenia.

A nurse is assisting in the care of a client who has chronic stress. The client states. i always feel so tired, but I can't sleep unless I have a cocktail or glass of wine at bedtime." Which of the following responses should the nurse make?

A nurse is collecting data from a group of clients who have anxiety disorders and have prescriptions for various psychotropic medications. The nurse should recognize which of the following clients as having an increased risk for suicide?

A nurse is caring for a client who has a serious mental illness and has developed tardive dyskinesia from anti-psychotic medication use. Which of the following adverse effects from anti-psychotic medication use would be expected for the client?

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 with the court-ordered admission of a client to a substance-abuse program. The client states, "You are all angry at me and wish you could go out and have a drink." The client's response is an example of which of the following defense mechanisms?

A nurse is caring for a client who is experiencing manifestations of opiate withdrawal. Which of the following medications should the nurse anticipate the provider to prescriber

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