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. "Avoid foods that contain tyramine" is not relevant to fluoxetine. Tyramine restriction is a concern with certain medications, such as monoamine oxidase inhibitors (MAOIs), but not with SSRIs like fluoxetine.

B. "Plan to discontinue this medication as soon as your depression is relieved" is not advisable. Discontinuing an antidepressant abruptly can lead to withdrawal symptoms and may not allow for the full resolution of depressive symptoms. The decision to discontinue medication should be made in consultation with a healthcare provider.

C. "Expect that your mood might take one to three weeks to begin improving" is a crucial piece of information to provide because fluoxetine, a selective serotonin reuptake inhibitor (SSRI), often takes a few weeks to start exerting its therapeutic effects. It's important for the client to understand that the full benefits of the medication may not be felt immediately.

D. "Stop taking this medication if weight loss or gain occurs" is not an appropriate instruction. Weight changes are potential side effects of fluoxetine, but the decision to continue or discontinue the medication should be based on consultation with a healthcare provider. Abruptly stopping medication without medical guidance can lead to withdrawal symptoms and is not recommended.

A. "What happened to you in the past to make you so desperate?" B. "What will you accomplish by taking your life?" C. "Why do you feel depressed enough to end your life?" D. How will you carry out your plan?"

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.

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Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has a new prescription for fluoxetine. Which of the following instructions should the nurse Include?

Correct Answer is C

Explanation

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 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 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?

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

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 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?