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 ["A","B","D","E"]

Explanation

A. Exhibiting clang associations: Correct. Clang associations involve the repetition of words or phrases based on sound rather than meaning and are often seen in manic states.

B. Interacting with others in a flirtatious way: Correct. Manic individuals may exhibit increased social and sexual behaviors, including being flirtatious.

C. Reports sleeping for long periods of time: Incorrect. Manic episodes are typically associated with decreased need for sleep rather than increased. Reports of sleeping for long periods would be more indicative of a depressive episode in bipolar disorder.

D. Talking in rapid continuous speech: Correct. Rapid and continuous speech is a common characteristic of manic episodes in bipolar disorder.

E. Reports spending large sums of money: Correct. Excessive spending is a common manifestation of manic behavior, often without consideration of the consequences.

A. "Everyone has trouble sleeping at times." B. "Why do you think you are so anxious?" C. Have you talked to your provider about this yet? D. It sounds like you're having a difficult time.

Correct Answer is C

Explanation

A. "Everyone has trouble sleeping at times" minimizes the client's concerns and may not address the underlying issues contributing to their anxiety.

B. "Why do you think you are so anxious?" might come across as judgmental or confrontational, and it may not create a supportive environment for the client to open up about their feelings.

C. "Have you talked to your provider about this yet?"
This response encourages the client to seek professional help and addresses the issue of increasing anxiety and difficulty sleeping. It is supportive and guides the client toward discussing their concerns with a healthcare provider who can assess the situation and provide appropriate interventions.

D. "It sounds like you're having a difficult time" acknowledges the client's distress but does not guide them toward seeking professional help. Encouraging a conversation with a healthcare provider is a more direct and helpful approach.

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a newly-admitted client who has bipolar disorder and is displaying manic behavior. Which of the following findings should the nurse expect? (Select all that apply.)

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

Explanation

A nurse is caring for a client who reports a state of increasing anxiety and the inability to sleep and concentrate. Which of the following is an appropriate response by the nurse?

Correct Answer is C

Explanation

A nurse is assisting with the plan of care for a client who is newly diagnosed with borderline personality disorder. Which of the following Interventions is the nurse's priority?

A nurse is caring for a client who is experiencing acute mania. Which of the following actions should the nurse take?

A nurse is assisting in the care of a client who has chronic stress. The client states. i always feel so tired, but I can't sleep unless I have a cocktail or glass of wine at bedtime." Which of the following responses should the nurse make?

A nurse is caring for a client who has bipolar disorder and states that his latest computer project is "revolutionizing the industry." Which of the following behaviors is the client exhibiting?

A nurse is caring for a client who has paranoid schizophrenia and a new prescription for risperidone. The client asks the nurse what the s is supposed to do. Which of the following responses should the nurse make?

A nurse is reinforcing teaching with a client who takes diazepam (Valium). Which of the following information should the nurse include?

A nurse is talking with a client who has schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things." Which of the following responses by the nurse is appropriate?

A nurse in a mental health facility is caring for a client who becomes upset and breaks a chair when a visitor does not arrive. The client remains agitated following initial verbal attempts to calm him down. Which of the following interventions should the nurse implement first?