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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

C. Constricted pupils, also known as miosis, are a classic sign of opioid intoxication. Opioids act on opioid receptors in the brainstem, which can lead to pupillary constriction.
A. Lability of mood refers to rapid and unpredictable changes in mood, which is not a typical finding in opioid intoxication.
B. Hypervigilance is not typically associated with opioid intoxication. Instead, opioid intoxication tends to cause CNS depression, leading to symptoms such as drowsiness, sedation, and impaired consciousness.
D. Opioid intoxication typically causes respiratory depression rather than increased respirations. Opioids depress the central respiratory drive, leading to shallow, slow, or irregular breathing patterns.

A. toxicity from the lithium carbonate. B. developing a tolerance to the lithium carbonate. C. stopping their prescribed lithium carbonate. D. consuming foods high in tyramine while taking lithium carbonate.

Correct Answer is A

Explanation

A. Lithium carbonate is a medication commonly used to treat bipolar disorder. Symptoms of lithium toxicity can include nausea, vomiting, diarrhea, muscle weakness, tremors, and flu-like symptoms. If a client is experiencing these symptoms after taking lithium carbonate, it could indicate lithium toxicity
B. Lithium is a mood stabilizer, and tolerance, in the sense of needing increasing doses to achieve the same effect, is not commonly observed.
C. Suddenly stopping lithium carbonate can lead to withdrawal symptoms, but the symptoms described— nausea, diarrhea, muscle weakness, and tremors—are more indicative of toxicity rather than withdrawal.
D. Tyramine is a compound found in certain foods and beverages, and interactions between tyramine-rich foods and certain medications, such as monoamine oxidase inhibitors (MAOIs), can lead to hypertensive crises. However, lithium carbonate is not known to have interactions with tyramine-rich foods.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has been taking oxycodone for pain. The client has returned three times for refills of the prescription. In addition to slurred speech, which assessment leads the nurse to suspect opioid Intoxication?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

A severely depressed, sullen client has been taking fluoxetine for 10 days. During the first outpatient visit, the client smiles excitedly and states, "I feel so much better now." How should the nurse interpret this behavior change? The:

When doing an admission assessment of a client with a history of alcoholism, the most important factor(s) to assess is/are:

A client notifies a treatment team member of current suicidal ideation. Which nursing intervention would take priority?

A nurse is caring for a 6-year old child suffering from separation anxiety. Which finding would a nurse expect when assessing the child? The child's:

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:

An individual with a history of antisocial personality disorder was arrested for driving under the influence of alcohol and causing a serious car accident. Which comment on this behavior would be expected?

A physician mentions to the nurse that a child with Attention Deficit-Hyperactivity Disorder (ADHD) will begin medication therapy. The nurse should prepare a plan to teach the family about:

The nurse is caring for a client who just received naloxone. Which nursing intervention is highest priority?