A coherent older client has been financially and emotionally abused by their adult children for the past several years but has not reported the abuse to anyone. Which is the most likely reason that the client has not reported the abuse?

The client cannot claim abuse if there is no evidence of physical harm.

Laws do not provide protection against abuse when the suspect(s) is/are family members.

The client has no financial resources to hire legal representation against the client's children.

The client is emotionally close to the children and does not want to bring them harm.

Answer and Explanation

The Correct Answer is D

D. Victims of abuse, especially perpetrated by family members, may feel conflicted about reporting the abuse due to feelings of guilt, shame, or fear of repercussions.

A. This implies that the client may believe they cannot report the abuse because they perceive abuse as only valid if there is physical evidence of harm. However, it's important to recognize that abuse can take various forms, including emotional, psychological, financial, and neglectful abuse, which may not always leave physical evidence.

B. While it's true that cases of abuse perpetrated by family members can be complex and challenging to address legally, there are laws and resources available to protect victims of family abuse. Many jurisdictions have laws specifically addressing domestic violence and elder abuse.

C. Reporting abuse to appropriate authorities, such as adult protective services or law enforcement, does not necessarily require hiring legal representation.

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Correct Answer is B

Explanation

B. This option promotes a calming and supportive environment that minimizes sensory stimuli and helps maintain orientation, reducing the risk of exacerbating symptoms of delirium and illusions.

A. Having the client sit by the nurse's desk may provide some supervision and reassurance, but keeping the television on can contribute to sensory overload and increase confusion, especially if the client is experiencing illusions.

C. Keeping the room shadowy with soft lighting and continuously playing a radio may create an environment that is disorienting and confusing for the client with delirium.

D. Maintaining bright lighting around the clock may disrupt the client's sleep-wake cycle and exacerbate symptoms of delirium. Interrupting the client's sleep by awakening hourly for mental status checks can also contribute to sleep deprivation and increase agitation and confusion

A. Monitor food intake and eliminate potential sources of tyramine. B. Assess for weight loss and difficulty sleeping. C. Monitor the client for migraines. D. Implement suicide precautions.

Correct Answer is D

Explanation

D. Children and adolescents with depression, especially when initiating or adjusting antidepressant medications like SSRIs, are at an increased risk of suicidal ideation and behavior. Therefore, it is crucial to prioritize the safety of the client by implementing suicide precautions, which may include close observation, removing potential means of self-harm, and involving the client in structured activities under supervision.

A. Monitoring food intake and eliminating potential sources of tyramine are considerations for clients taking monoamine oxidase inhibitors (MAOIs), another class of antidepressant medications, due to the risk of hypertensive crisis.

B. Weight loss and difficulty sleeping are potential side effects of SSRIs that may occur, particularly during the initial phases of treatment. However, suicide precautions are a priority

C. While SSRIs may cause headaches or migraines as potential side effects, monitoring for migraines specifically would not typically be a priority

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A coherent older client has been financially and emotionally abused by their adult children for the past several years but has not reported the abuse to anyone. Which is the most likely reason that the client has not reported the abuse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with delirium who is experiencing illusions. What environmental conditions should the nurse arrange for this client?

Correct Answer is B

Explanation

An 11-year-old client has been hospitalized on the adolescent psychiatry unit with severe depression. For the past several weeks, the client has been prescribed a selective serotonin reuptake inhibitor (SSRI). What is the priority nursing action?

Correct Answer is D

Explanation

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