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

Answer and Explanation

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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Correct Answer is D

Explanation

D. Mania is characterized by symptoms such as increased energy levels, decreased need for sleep, impulsivity, racing thoughts, and agitation. Disorganized thinking, rapid speech, and an inability to remain seated are common manifestations of manic symptoms.
A. Clients in a manic episode often exhibit rapid speech, tangential thinking, and may be overly talkative rather than providing short, polite responses.
B. Manic individuals typically exhibit heightened energy levels, impulsivity, and distractibility, making it challenging for them to engage in introspection or focus on the present situation. Instead, they may be preoccupied with grandiose ideas, racing thoughts, or engaging in excessive activities.
C. This response is more characteristic of individuals experiencing depressive episodes of bipolar disorder rather than manic episodes. During a depressive episode, individuals with bipolar disorder may experience profound feelings of sadness, hopelessness, and helplessness, along with symptoms such as fatigue, changes in appetite or weight, and sleep disturbances.

A. "I understand that the goal of my recovery is to decrease my drinking." B. "I realize that recovery is a life-long process that comes in steps." C. "Al-Anon can assist me in my recovery process." D. "Once I have detoxed, my recovery is complete."

Correct Answer is B

Explanation

B. It acknowledges that recovery is not a quick fix or a one-time event but rather a lifelong journey that involves ongoing effort, self-awareness, and personal growth. Recognizing that recovery occurs in steps suggests an understanding of the incremental progress and challenges that may be encountered along the way.
A. This statement demonstrates some understanding of the concept of recovery from alcohol abuse, but it may not fully reflect the comprehensive nature of recovery.
C. Al-Anon is a mutual support program for people affected by someone else's alcoholism, typically family members and friends. This does not directly involve the client.
D. Detoxification, or the process of clearing alcohol and its byproducts from the body, is an important initial step in recovery, but it is not synonymous with recovery itself.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A family describes a client diagnosed with bipolar disorder as being "on the move." The client sleeps 3-4 hours nightly, spends excessively, and has recently lost 10 pounds. During the initial client assessment, which response would the nurse expect?

Correct Answer is D

Explanation

The nurse is educating clients about recovery from alcohol abuse. Which statement indicates that learning has occurred?

Correct Answer is B

Explanation

A client plans to go to an acupuncturist for complementary treatment of alcoholism. He asks the nurse to explain how acupuncture works. The most accurate response would be "Acupuncture is a traditional Chinese medical treatment. The Chinese believe that:

A client is admitted to a Chemical Addictions Unit to stop using alcohol and to learn about sobriety. The client asks the nurse what medication the doctor has prescribed for possible alcohol withdrawal. The nurse explains that the physician prescribed:

A client with a history of a suicide attempt has been discharged and is being followed in an outpatient clinic. What is/are the most appropriate nursing intervention(s)? (SELECT ALL THAT APPLY)

Which statement by an Emergency Department nurse indicates accurate knowledge of domestic violence?

A client who has just been raped arrives at the Emergency Room. The client is crying, pacing and cursing their attacker. Which is the priority therapeutic statement for the nurse to make?

The nurse is planning a psycho-education group for clients diagnosed with borderline personality disorder. The nurse understands that which aspect of group intervention is most essential initially to establish a trusting nurse-patient relationship?

The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. Which screening tool should the nurse use to further evaluate this possibility?

A nurse is caring for a 10-year old child with Intellectual Developmental Disorder who has an IQ of 45. Which child capability would the nurse expect to observe? The child: