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. Alcohol withdrawal can lead to dehydration due to symptoms such as vomiting, diarrhea, and increased urination. Replacing fluids is important to prevent dehydration and maintain electrolyte balance.
A. Orienting the individual to reality involves helping them understand their current situation and surroundings. While this is an important aspect of nursing care, it may not be the highest priority during the initial phase of alcohol withdrawal.
B. Social support is vital for individuals undergoing alcohol withdrawal, as it can provide emotional reassurance and assistance during a challenging time. However, during the initial phase of withdrawal, the highest priority is typically addressing immediate physiological needs.
D. Restraints should only be used as a last resort and in situations where there is an imminent risk of harm to the individual or others.

A. "Power and control are central to the dynamic of domestic violence." B. "Erratic relationships and vulnerability are central to the dynamic of domestic violence." C. "Poor communication and social isolation are central to the dynamic of domestic violence." D. "Emotional injury and learned helplessness are central to the dynamic of domestic violence."

Correct Answer is A

Explanation

A. Domestic violence is not simply about physical violence but also involves an imbalance of power where the abuser seeks to exert control over the victim through various means, including emotional, psychological, financial, and social manipulation.
B. Domestic violence can certainly lead to erratic relationships and exacerbate feelings of vulnerability but this statement does not capture the central dynamic of power and control that characterizes domestic violence.
C. Poor communication and social isolation can be contributing factors in some cases of domestic violence but they are not necessarily central to the dynamic.
D. This statement partially captures the psychological impact of domestic violence on victims, including emotional injury and learned helplessness. However, it does not explicitly address the underlying dynamic of power and control.

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Naxlex Comprehensive Predictor Exams

The highest priority nursing action relative to the initial phase of alcohol withdrawal would be to:

Correct Answer is C

Explanation

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

Correct Answer is A

Explanation

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

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