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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Related Questions
Correct Answer is C
Explanation
C. This statement demonstrates an understanding of the availability of support groups specifically for family members affected by alcohol use disorder and reflects the spouse's willingness to seek support independently of the client's readiness for treatment.
A. Effective teaching would convey that support groups are available not only for individuals struggling with alcohol use disorder but also for their family members who may need support in coping with the impact of the disorder on their lives.
B. Alcoholics Anonymous (AA) meeting are primarily for individuals with alcohol use disorder.
D. Effective teaching would emphasize the importance of the family seeking support for themselves independently of the client's readiness to seek treatment.
Correct Answer is B
Explanation
B. The combination of paroxetine and St. John's Wort can lead to a potentially life-threatening condition known as serotonin syndrome. It is important for healthcare providers to be aware of potential drug interactions and to monitor patients closely when changes to their medication regimen occur.
A. Using a heating pad may provide temporary relief for muscle stiffness but does not address the underlying cause of the symptoms.
C. Given the symptoms described, involving an orthopedic doctor is not appropriate as the symptoms are not related to musculoskeletal issues.
D. A clear liquid diet and bed rest do not address the underlying issue in the client hence not an appropriate action.
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