The nurse notes old and new ecchymotic areas on an older adult client's arms and buttocks upon admission. The client tells the nurse in confidence that her family members frequently hit her. Which statement should the nurse use in response?

‘’I have a legal obligation to report this type of abuse."

"Let's get these treated, and I will maintain confidence."

"Let's talk about ways to prevent someone from hitting you"

"If this happens again, you must call the emergency department."

Answer and Explanation

The Correct Answer is A

A) "I have a legal obligation to report this type of abuse."
The nurse has a legal and ethical obligation to report suspected abuse or neglect, especially in vulnerable populations such as older adults. In many jurisdictions, mandatory reporting laws require healthcare professionals to report suspected abuse to the appropriate authorities (e.g., Adult Protective Services, law enforcement) to ensure the safety of the client.

B) "Let's get these treated, and I will maintain confidence."
While it is essential to provide care for the physical injuries, the nurse cannot promise to maintain confidence in cases of suspected abuse. Confidentiality can be breached in situations where a legal obligation to report abuse exists. Failing to report suspected abuse could jeopardize the client's safety and place the nurse at risk of legal consequences.

C) "Let's talk about ways to prevent someone from hitting you."
This might seem compassionate, but it does not address the legal obligation to report the abuse. The priority should be to ensure the client's safety by reporting the situation to the appropriate authorities. Focusing on preventative measures without reporting the abuse first may imply that the responsibility lies with the client to prevent the abuse, rather than ensuring that the perpetrator is held accountable and the client is protected from harm.

D) "If this happens again, you must call the emergency department."
While advising the client to call the emergency department is a reasonable step in cases of immediate harm, it does not address the current abuse or the need for immediate intervention. The nurse's primary responsibility is to report the abuse to the proper authorities and ensure the client's safety.

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Correct Answer is C

Explanation

A) Improved bladder function:
Diphenhydramine, an antihistamine, has anticholinergic properties, meaning it blocks acetylcholine, which can cause side effects like urinary retention and dry mouth. While it may increase urinary retention, it is not primarily used to treat bladder function issues in Parkinson's disease.

B) Relief of depression:
Diphenhydramine is not prescribed for the treatment of depression in Parkinson's disease. It is an antihistamine used to treat allergic reactions and motion sickness, and sometimes for its anticholinergic effects in Parkinson's disease. While it may cause sedation, it does not address the neurochemical imbalances in the brain that cause depression, which is often treated with antidepressants such as SSRIs or SNRIs.

C) Decreased tremors:
Diphenhydramine has anticholinergic properties, which can help reduce tremors in patients with Parkinson's disease. Parkinson's disease is associated with a dopamine deficit, but acetylcholine also plays a role in motor control. The use of anticholinergic medications, such as diphenhydramine, can help restore balance between dopamine and acetylcholine in the brain, leading to decreased tremors.

D) Delay in disease progression:
There is no evidence that diphenhydramine can delay the progression of Parkinson's disease. The disease is caused by the degeneration of dopamine-producing neurons in the brain, and current treatments, such as levodopa/carbidopa or dopamine agonists, primarily aim to manage symptoms rather than prevent progression.

A. Continue to monitor as this is a normal response to the medication B. Administration of atropine C. Place the patient in the trendelenburg position D. Administer diphenhydramine (Benadryl) for the allergic reaction

Correct Answer is B

Explanation

A) Continue to monitor as this is a normal response to the medication: The symptoms the patient is experiencing (cramping, diaphoresis, increased oral secretions) are not normal responses to the edrophonium test and suggest a cholinergic crisis rather than a simple reaction to the medication. A cholinergic crisis occurs when there is overmedication with cholinergic drugs, leading to excessive stimulation of the parasympathetic nervous system. While mild effects like slight nausea or dizziness can occur, cramping, diaphoresis, and increased oral secretions indicate toxicity, requiring immediate intervention.

B) Administration of atropine: The symptoms the patient is exhibiting—cramping, diaphoresis, and increased oral secretions—are indicative of cholinergic toxicity. Edrophonium, a cholinesterase inhibitor, is used in the Tensilon test to diagnose myasthenia gravis by temporarily improving muscle strength. However, in some cases, the patient may experience a cholinergic crisis from an overdose of the medication, resulting in excess acetylcholine at synapses, which overstimulates the parasympathetic nervous system. Atropine, an anticholinergic agent, blocks the effects of acetylcholine and is used to reverse these symptoms by reducing the excessive parasympathetic activity (e.g., reducing secretions and improving heart rate).

C) Place the patient in the Trendelenburg position: The Trendelenburg position (head down, feet up) is often used in cases of shock to help increase venous return to the heart. However, it is not appropriate for a cholinergic crisis. The patient’s symptoms are not due to hypotension or shock but are related to an overdose of edrophonium causing parasympathetic overstimulation.

D) Administer diphenhydramine (Benadryl) for the allergic reaction: The symptoms the patient is experiencing (cramping, diaphoresis, increased oral secretions) are not related to an allergic reaction. Diphenhydramine (Benadryl) is an antihistamine used for allergic reactions, such as urticaria or anaphylaxis, but it does not treat cholinergic toxicity.

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The nurse notes old and new ecchymotic areas on an older adult client's arms and buttocks upon admission. The client tells the nurse in confidence that her family members frequently hit her. Which statement should the nurse use in response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Correct Answer is B

Explanation

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