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. Hyperexcitability is not typically associated with major depressive disorder. In fact, individuals with depression often experience a decrease in energy, motivation, and overall activity levels.

B. Significant change in weight.
Major depressive disorder (MDD) is often associated with changes in appetite and weight. Clients with MDD may experience either weight loss or weight gain. This can result from changes in eating habits related to the individual's emotional state.

C. Exaggerated response of pleasure to stimuli is not a characteristic finding in major depressive disorder. In contrast, individuals with depression may experience anhedonia, which is a reduced ability to experience pleasure from previously enjoyable activities.

D. Attention-seeking behavior is not a specific characteristic of major depressive disorder. Individuals with depression may withdraw socially and experience difficulties in concentration and attention.

A. Neologism B. Clang association C. Echolalla D. Word salad

Correct Answer is A

Explanation

A. Neologism.
Neologism is a language disturbance in which the individual creates new, idiosyncratic words that have meaning only to the individual. In this case, the client's use of "mazuka" is an example of a neologism as it is a made-up word that holds significance only for the client.

B. Clang association involves the association of words based on sound rather than meaning.

C. Echolalia is the repetition of words or phrases spoken by others.

D. Word salad refers to a jumble of words and phrases that lack coherent meaning or logical connection.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is B

Explanation

A nurse overhears a client who has schizophrenia talking to herself. The client keeps stating "The muxtranks are coming. The muntranks are coming. The nurse correctly recognizes the client's use of the word mazuka as an example of which of the following alterations in speech?

Correct Answer is A

Explanation

A nurse is assisting with the plan of care for a client who is newly diagnosed with borderline personality disorder. Which of the following Interventions is the nurse's priority?

A nurse is caring for a client who has obsessive compulsive disorder (OCD) and is constantly picking up after others and cleaning in the day room. The nurse should recognize the client's actions as which of the following?

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 collecting data from a newly-admitted client who has bipolar disorder and is displaying manic behavior. Which of the following findings should the nurse expect? (Select all that apply.)

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