An 85-year-old client is seen in the Emergency Department after a fall at home. The client is slightly confused, malnourished, and severely dehydrated. The client is reluctant to say what happened and her daughter constantly interrupts, not allowing the client to answer. Which of the following nursing interventions is a priority?

Request a psychiatric evaluation for the client

Interview the client alone and assess for abuse

Provide the daughter and client with nutritional counseling

Take the history from the daughter because of the client's confusion

Answer and Explanation

The Correct Answer is B

B. Given the client's confusion and the daughter's behavior of constantly interrupting and not allowing the client to answer, there may be concerns about elder abuse or neglect. It's essential to create a safe and private environment for the client to speak freely without interference.
A. The client's confusion and reluctance to speak may raise concerns about their mental status. However, requesting a psychiatric evaluation is not the priority in this scenario. The client's immediate needs, including hydration, nutrition, and safety, should be addressed first.
C. Addressing malnutrition is important but providing nutritional counseling is not the priority in this scenario. The client's severe dehydration and potential abuse or neglect take precedence over nutritional concerns.
D. Obtaining information from the daughter may be helpful but it should not be the sole source of information, especially if there are concerns about the daughter's behavior and potential interference with the client's ability to communicate.

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Correct Answer is B

Explanation

B. Multiple visits of the same child with different injuries could be a significant red flag for possible child abuse. Patterns of repeated injuries or injuries inconsistent with the child's developmental stage or reported activities may indicate a pattern of maltreatment.
A. While accidental injuries can occur, a dislocated shoulder in a 1-year-old child from arm swinging seems unlikely and may warrant further investigation.
C. Breaking a bone, such as an arm, can occur accidentally during childhood play or activities and the behavior of the child clinging to the mother is expected in moments of pain.
D. Middle ear infections are common in childhood and typically do not raise suspicion of abuse on their own.

A. Short, polite responses to interview questions B. Introspection related to present situation C. Feelings of helplessness and hopelessness D. Disorganized thinking and the inability to remain seated.

Correct Answer is D

Explanation

D. Mania is characterized by symptoms such as increased energy levels, decreased need for sleep, impulsivity, racing thoughts, and agitation. Disorganized thinking, rapid speech, and an inability to remain seated are common manifestations of manic symptoms.
A. Clients in a manic episode often exhibit rapid speech, tangential thinking, and may be overly talkative rather than providing short, polite responses.
B. Manic individuals typically exhibit heightened energy levels, impulsivity, and distractibility, making it challenging for them to engage in introspection or focus on the present situation. Instead, they may be preoccupied with grandiose ideas, racing thoughts, or engaging in excessive activities.
C. This response is more characteristic of individuals experiencing depressive episodes of bipolar disorder rather than manic episodes. During a depressive episode, individuals with bipolar disorder may experience profound feelings of sadness, hopelessness, and helplessness, along with symptoms such as fatigue, changes in appetite or weight, and sleep disturbances.

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Naxlex Comprehensive Predictor Exams

Several children are seen in the ER for treatment of illnesses and injuries daily. The situation that would cause the nurse to have a high suspicion of child abuse would be:

Correct Answer is B

Explanation

A family describes a client diagnosed with bipolar disorder as being "on the move." The client sleeps 3-4 hours nightly, spends excessively, and has recently lost 10 pounds. During the initial client assessment, which response would the nurse expect?

Correct Answer is D

Explanation

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