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 C

Explanation

C. Acceptance and trust create a sense of safety and security for the client within the therapeutic relationship. When the client feels accepted and valued by the nurse, they are more likely to feel comfortable opening up and engaging in the therapeutic process.
A. Establishing a therapeutic alliance provides a safe and supportive environment for the client to express their feelings without fear of judgment or rejection. However, therapeutic alliance goes beyond this.
B. Therapeutic activities can indeed provide an outlet for tension and stress but the establishment of a therapeutic alliance goes beyond engaging in specific activities.
D. Focusing on positive behaviors and strengths can contribute to building self-esteem. However, the establishment of a therapeutic alliance involves more than just focusing on behaviors.

A. Potato chips and diet Coke B. Bagels with cream cheese and tea C. Apple pie and coffee D. Pepperoni pizza and red wine

Correct Answer is D

Explanation

D. Pepperoni pizza and red wine are both high in tyramine and should be avoided when taking MAOIs. The aging and fermentation processes involved in the production of pepperoni and red wine increase the tyramine content, which can lead to a dangerous increase in blood pressure when combined with MAOIs.
A. Potato chips are generally considered safe to eat in moderation with MAOIs, as they do not contain high levels of tyramine. Diet Coke is also considered safe as it does not contain tyramine.
B. Bagels with cream cheese typically do not contain high levels of tyramine, and tea is generally considered safe to consume with MAOIs.
C. Apple pie may contain moderate levels of tyramine, particularly if it contains aged or fermented apples. However, the tyramine content in apple pie is generally not high enough to pose a significant risk when consumed in moderation. Coffee, on the other hand, contains tyramine, but the amount is usually not enough to cause a severe reaction.

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Naxlex Comprehensive Predictor Exams

The nurse working with a teen, who has a history of being moody and withdrawn, will make the establishment of a therapeutic alliance a priority because:

Correct Answer is C

Explanation

A psychiatrist prescribes a monoamine oxidase inhibitor (MAOI) for a client. When teaching the client about the effects of tyramine, which foods will the nurse caution the client to avoid?

Correct Answer is D

Explanation

A client who is prescribed lithium carbonate is being discharged from inpatient care. Which medication information should the nurse teach this client?

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