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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

D. This behavior suggests the possibility of suicidal ideation, which is a medical emergency in mental health care. The nurse should assess the client for suicidal thoughts, intentions, and plans, and provide a safe environment to prevent self-harm. It's crucial to address this as a priority to ensure the safety and well- being of the client.
A. Withdrawing from social interactions can be a symptom of depression. However, it may not always be the highest priority intervention
B. This behavior suggests agitation and potential delusional thinking, which can be indicative of a severe depressive episode or a mixed state in bipolar disorder. This however, does not indicate the need for immediate intervention.
C. Non-adherence to prescribed medication, particularly mood stabilizers, can significantly impact the management of bipolar disorder and increase the risk of mood destabilization. However, addressing adherence is not the priority intervention.

A. client may have decided to carry out the suicide plan. B. medication has potentiated serotonin syndrome. C. medication dosage should be decreased. D. client's behavioral change is normal and expected.

Correct Answer is D

Explanation

D. This recognizes that the client's improvement in mood is a typical response to antidepressant medication and does not automatically suggest any negative outcomes such as suicidal ideation or serotonin syndrome.
A. It's important to be vigilant for signs of suicidal ideation but sudden improvements in mood can also occur as a positive response to antidepressant medication.
B. The client's description of feeling better does not align with the symptoms of serotonin syndrome, which include agitation, confusion, rapid heart rate, high blood pressure, and hyperthermia.
C. Antidepressant medications often take several weeks to reach their full therapeutic effect, so it's not unusual for some clients to experience an improvement in mood within the first few weeks of treatment.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with bipolar disorder is experiencing a severe depressive episode. Which client behavior would alert the nurse to the highest priority intervention? The client:

Correct Answer is D

Explanation

A severely depressed, sullen client has been taking fluoxetine for 10 days. During the first outpatient visit, the client smiles excitedly and states, "I feel so much better now." How should the nurse interpret this behavior change? The:

Correct Answer is D

Explanation

A client diagnosed with borderline personality disorder is admitted to a psychiatric unit. Which behavior pattern would the nurse expect to observe?

The intervention appropriate for a client who has been manipulating others and has a diagnosis of antisocial personality disorder is to:

When assessing a 2-year-old child with suspected autism spectrum disorder, the nurse should be particularly alert for:

The nurse is caring for a client who is experiencing mania. The client is pacing, cannot sit, and has pressured speech. Which meal will the nurse provide to best meet the nutritional needs of this client?

A fifteen-year-old was referred to the adolescent mental health clinic after being arrested for prostitution. The client's parents reported that they have run away several times and is abusive towards them. The nurse should anticipate that the diagnosis will be:

A physician mentions to a nurse that a newly admitted client is impulsive. The nurse should assess for behavior characterized by:

A psychiatrist prescribes a monoamine oxidase inhibitor (MAOI) for a client. When teaching the client about the effects of tyramine, which foods will the nurse caution the client to avoid?

A nurse is caring for a 10-year old child with Intellectual Developmental Disorder who has an IQ of 45. Which child capability would the nurse expect to observe? The child: