A nurse is conducting a home health visit for an older adult client who lives with family members. The nurse notices that the client has multiple unusual bruises, and, based on several other factors, the nurse suspects that the client has been physically abused. Which of the following actions should the nurse take first?

Check the bruises at the next visit to the client's home.

Follow the agency's guidelines for reporting suspected abuse.

Institute more frequent visits to the client's home.

Arrange referral for family therapy to deal with home stressors.

Answer and Explanation

The Correct Answer is B

A. Checking the bruises at the next visit may delay necessary intervention. If abuse is suspected, immediate action, such as reporting, is essential to protect the client.

B. Following the agency's guidelines for reporting suspected abuse is the priority when abuse is suspected. Reporting abuse to the appropriate authorities, such as adult protective services or law enforcement, is crucial to ensure the safety and well-being of the older adult.

C. Instituting more frequent visits to the client's home might be part of a safety plan, but it should not be the first action. Reporting suspected abuse is the priority to involve the appropriate authorities.

D. Arranging a referral for family therapy is not the first step in suspected elder abuse. Safety and protection of the older adult take precedence. Once the immediate safety concerns are addressed, additional interventions, such as family therapy, may be considered.

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Correct Answer is B

Explanation

A. Diphenhydramine is an antihistamine and is not typically used to manage opiate withdrawal. It may help with certain symptoms like insomnia or mild anxiety but is not a primary treatment for opioid withdrawal.

B. Methadone is commonly used in the treatment of opioid withdrawal. It is a long-acting opioid agonist that helps manage withdrawal symptoms and cravings, providing a more controlled tapering process. Methadone is often used in medication-assisted treatment (MAT) for opioid use disorder.

C. Benzodiazepines are not typically used as the first-line treatment for opioid withdrawal. They may be considered in specific situations, such as when there is severe anxiety or agitation, but they are generally not the primary choice due to the risk of dependence.

D. Naloxone is an opioid antagonist used to reverse opioid overdose. It is not used in the routine management of opioid withdrawal but rather in emergency situations where opioid overdose is suspected.

A. Sodium level B. Blood pressure C. Respiratory rate D. Capillary refill E. Glucose level F. Phosphate level G. Magnesium level

Correct Answer is ["A","B","D"]

Explanation

A. Sodium level: Correct. Sodium imbalances can have serious consequences, including neurological symptoms. Hyponatremia is a common electrolyte imbalance seen in anorexia nervosa.

B. Blood pressure: Correct. Abnormal blood pressure, especially low blood pressure, can indicate cardiovascular compromise, which is a concern in severe cases of anorexia nervosa.

C. Respiratory rate: Not selected. While monitoring respiratory rate is important, the client's pallor and capillary refill suggest potential issues with peripheral perfusion, making capillary refill more urgent.

D. Capillary refill: Correct. Prolonged capillary refill time is a measure of peripheral perfusion and may indicate poor tissue perfusion, requiring immediate attention.

E. Glucose level: Not selected. While monitoring glucose levels is important, hypoglycemia might not be an immediate concern in this scenario. The client's neurological symptoms may be more related to electrolyte imbalances.

F. Phosphate level: Not selected. Monitoring phosphate levels is important, but severe abnormalities may not require immediate follow-up unless other critical issues are addressed first.

G. Magnesium level: Not selected. Magnesium imbalances are significant but may not require immediate follow-up unless severe abnormalities are noted.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is experiencing manifestations of opiate withdrawal. Which of the following medications should the nurse anticipate the provider to prescriber

Correct Answer is B

Explanation

Correct Answer is ["A","B","D"]

Explanation

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