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 C

Explanation

A. Identification: Identification involves taking on the characteristics of another person, group, or entity. The client's response is not an example of identification.

B. Relation-formation: This term is not a recognized defense mechanism in the context of classical psychoanalytic theory. It seems to be a combination of two concepts but doesn't fit the context of the client's statement.

C. Projection
Projection is a defense mechanism where an individual attributes their own unacceptable thoughts, feelings, or impulses to another person. In this scenario, the client is projecting their own feelings of anger and a desire to have a drink onto the nurse and others, suggesting that the staff is angry at them and wants to go out for a drink.

D. Compensation: Compensation involves making up for a perceived weakness by emphasizing a strength in another area. The client's statement do

A. Foods that are known to be high in dietary tyramine should be avoided B. increase the dose of medication as needed if relief of manifestations is not experienced. C. Avoid driving or eating heavy machinery until you know how alprazolam affects you D. manifestations should be expected after a few weeks of therapy.

Correct Answer is C

Explanation

A. Foods that are high in dietary tyramine are more relevant to certain antidepressant medications, particularly monoamine oxidase inhibitors (MAOIs), and are not a specific concern with alprazolam.

B. Increasing the dose of the medication without consulting the healthcare provider is not appropriate. Adjustments to the dosage should be done under the guidance of the healthcare provider.

C. Avoid driving or operating heavy machinery until you know how alprazolam affects you.
This is an important safety consideration when using benzodiazepines such as alprazolam. Benzodiazepines can cause drowsiness and impair coordination, so clients should be advised to avoid activities that require mental alertness, such as driving or operating machinery, until they are aware of how the medication affects them.

D. Manifestations of anxiety should improve with the use of alprazolam, and relief of symptoms can occur relatively quickly. However, it is essential to inform the client that long-term use of benzodiazepines may lead to tolerance and dependence. They should not abruptly stop the medication without consulting their healthcare provider.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

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?

Correct Answer is 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?

A nurse is caring for a client who witnessed her brother's homicide and has posttraumatic stress disorder (PTSD). Which of the following findings should the nurse expect?

A nurse is caring for a client who is experiencing acute mania. Which of the following actions should the nurse take?

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