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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The client's lethargy and lack of response to verbal commands raise concerns about their level of consciousness and potential airway compromise. Assessing the client's airway and breathing involves ensuring that the airway is clear, assessing respiratory rate and effort, and monitoring oxygenation.
B. Assessing the gag reflex can provide additional information about airway protection. However, it should not delay assessment and intervention for airway and breathing concerns.
C. Contacting the physician may be necessary but it is not the priority nursing action in this situation. The nurse should first assess the client's airway and breathing to ensure their safety and stability.
D. The client's lethargy and unresponsiveness are not normal findings after an endoscopy and require immediate assessment and intervention. Delaying assessment and intervention could lead to serious complications, including respiratory compromise or airway obstruction.
Correct Answer is B
Explanation
B. Children with ASD may show reduced interest in social interactions, have difficulty understanding social cues, and may not engage in typical play with peers or caregivers. They might also exhibit challenges with nonverbal communication, such as making eye contact or using gestures.
A. While hyperactivity and attention deficits can be present in children with ASD, they are not as specific to the diagnosis as impaired social skills.
C. High levels of anxiety when separated from the mother could be seen in many conditions and are not particularly indicative of ASD.
D. A history of disobedience and destructive acts could be seen in many conditions and are not particularly indicative of ASD.
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