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 C

Explanation

C. Digoxin toxicity is a serious condition that can occur when there is too much digoxin in the body. It can lead to life-threatening cardiac dysrhythmias. One of the risk factors for digoxin toxicity is low blood levels of potassium, or hypokalemia.
A. Electrolyte imbalances, including hyponatremia (low sodium levels), can contribute to digoxin toxicity. However, a sodium level of 133 mg/dl alone does not directly indicate digoxin toxicity.
B. Blood glucose levels within the normal range (80-120 mg/dl) would not directly indicate digoxin toxicity.
D. Calcium levels within the normal range (8.5-10.5 mg/dl) do not directly indicate digoxin toxicity.

A. Marital harmony in the household B. Being raised by multiple caregivers C. Regular prenatal care for the mother D. Developmental milestones achieved on schedule

Correct Answer is B

Explanation

B. Children who are raised by multiple caregivers may experience challenges in forming secure attachments, receiving consistent discipline and support, and maintaining stability in their environment. These disruptions can contribute to emotional insecurity, behavioral problems, and difficulties in social relationships, which are risk factors for the development of psychiatric disorders.
A. Marital harmony in the household is generally considered a protective factor rather than a predisposing factor for the development of psychiatric disorders in children.
C. Regular prenatal care for the mother is generally considered a protective factor for the child's development rather than a predisposing factor for psychiatric disorders.
D. Achieving developmental milestones on schedule indicates healthy neurological and cognitive development, as well as appropriate social and emotional functioning.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse should monitor the client for signs and symptoms of digoxin toxicity if the laboratory report reflects a serum:

Correct Answer is C

Explanation

Which predisposing factor obtained during the nursing assessment would cause the nurse to consider a child to be at risk for the development of a psychiatric disorder?

Correct Answer is B

Explanation

When doing an admission assessment of a client with a history of alcoholism, the most important factor(s) to assess is/are:

The nurse is scheduled to interview a client with histrionic personality disorder. The nurse can anticipate that the assessment findings will include the following. The client:

A client has just been admitted to the Post Anesthesia Care Unit after electroconvulsive therapy (ECT). Which intervention will the nurse perform first?

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

When assessing a client diagnosed with narcissistic personality disorder, the nurse expects to identify which characteristic behavior?

The client asks the nurse about pet therapy. Which response by the nurse provides the client with accurate information? "Pet therapy:

An individual with a history of antisocial personality disorder was arrested for driving under the influence of alcohol and causing a serious car accident. Which comment on this behavior would be expected?