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 B

Explanation

B. It's essential for the client to receive accurate information about their safety, efficacy, and potential interactions with other medications. Health food store employees may not always have the necessary expertise to provide comprehensive information on these aspects.
A. Yoga can indeed improve flexibility and balance, which can be beneficial for individuals with osteoarthritis. Therefore, this choice does not indicate a need for client teaching.
C. Glucosamine helps with pain control and bone remodeling to improve overall functionality.
D. Prayer and spirituality can provide emotional support and improve overall well-being, they may not directly address the underlying physical symptoms of osteoarthritis. This may indicate a need for client teaching, as it may reflect the client's personal beliefs and coping strategies.

A. Open the crash cart. B. Administer oxygen via nonrebreather. C. Administer naloxone. D. Contact the parents.

Correct Answer is C

Explanation

C. Administering naloxone is often the priority action for a client exhibiting symptoms of opiate intoxication, especially if they are experiencing significant respiratory depression or unconsciousness. Naloxone is a medication used to rapidly reverse the effects of opioids, including respiratory depression and sedation.
A. Opening the crash cart is not the priority action for a client exhibiting symptoms of opiate intoxication unless the client's condition deteriorates rapidly, leading to a life-threatening emergency such as respiratory depression or cardiac arrest.
B. This intervention is important for clients experiencing respiratory depression, hypoxemia, or altered mental status due to opiate overdose. However, it may not be the highest priority action if the client's respiratory status is stable
D. Contacting the client's parents or guardians is important for obtaining medical history, consent for treatment (if applicable), and support. However, it may not be the highest priority action in the immediate management of opiate intoxication.

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Naxlex Comprehensive Predictor Exams

The nurse is admitting a client who has osteoarthritis. Which information obtained by the nurse indicates a need for client teaching? The client:

Correct Answer is B

Explanation

The nurse in the Emergency Department (ED) assesses a 17-year-old client exhibiting symptoms of opiate intoxication. Which of the following should be the nurse's priority action?

Correct Answer is C

Explanation

Which predisposing factor obtained during the nursing assessment would cause the nurse to consider a child to be at risk for the development of a psychiatric disorder?

The intervention appropriate for a client who has been manipulating others and has a diagnosis of antisocial personality disorder is to:

When assessing a client diagnosed with narcissistic personality disorder, the nurse expects to identify which characteristic behavior?

A client diagnosed with bipolar disorder is experiencing a severe depressive episode. Which client behavior would alert the nurse to the highest priority intervention? The client:

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

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?

A client has just been admitted to the Post Anesthesia Care Unit after electroconvulsive therapy (ECT). Which intervention will the nurse perform first?