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 ["A"]

Explanation

A) Hydration with IV fluids:
IV hydration may be ordered to improve kidney function and help facilitate the excretion of excess digoxin from the body. Digoxin toxicity is often related to impaired renal clearance, so improving hydration can promote renal perfusion and enhance the elimination of the drug. This is a common supportive measure to help in managing digoxin toxicity.

B) Nothing as the digoxin level is within normal ranges:
This is incorrect because the patient's digoxin level is 4 ng/ml, which is significantly above the normal therapeutic range of 0.8–2.0 ng/ml. A level of 4 ng/ml is toxic, and immediate action is required. Symptoms like severe bradycardia, nausea, and vomiting are indicative of digoxin toxicity, and they necessitate prompt intervention.

C) Hold the Digoxin:
In the case of digoxin toxicity, it is crucial to hold the digoxin. Digoxin should be discontinued immediately if toxicity is suspected, as continuing the medication could worsen symptoms like bradycardia and increase the risk of potentially life-threatening arrhythmias. This step is essential to prevent further complications.

D) Digibind:
Digibind (Digoxin immune fab) is a digoxin-specific antibody used in cases of severe digoxin toxicity or overdose. It binds to the digoxin molecules and helps to neutralize its effects. Given the elevated level of digoxin (4 ng/ml) and the presence of symptoms like severe bradycardia, nausea, and vomiting, Digibind is likely to be ordered to reverse the effects of the toxicity.

E) Narcan:
Narcan (naloxone) is used to reverse opioid overdoses, not digoxin toxicity. There is no indication for the use of Narcan in this scenario, as digoxin toxicity does not involve opioid overdose. This intervention would be inappropriate and irrelevant to the management of digoxin toxicity.

A. Class II B. Class IV C. Class I D. Class IlI

Correct Answer is A

Explanation

A) Class II:
According to the New York Heart Association (NYHA) classification of heart failure, Class II is characterized by slight limitation in physical activity. Patients in this class are comfortable at rest but experience symptoms (such as fatigue, palpitations, or shortness of breath) during ordinary physical activity. This description fits the client's reported symptoms, which include comfort at rest and the onset of symptoms with routine activity, such as walking or climbing stairs.

B) Class IV:
Class IV is the most severe stage of heart failure. Patients in this class are unable to carry out any physical activity without discomfort and experience symptoms at rest, such as shortness of breath or fatigue. The symptoms do not improve with rest, and even minimal exertion exacerbates the condition.

C) Class I:
Class I heart failure is characterized by no limitation in physical activity. Patients in this class are able to carry out ordinary physical activity without fatigue, palpitations, or dyspnea. Since this client experiences symptoms with ordinary activity, they do not meet this criteria.

D) Class III:
Class III represents patients with marked limitation of physical activity. They are comfortable at rest, but less than ordinary activity causes fatigue, palpitations, or shortness of breath. While this client does report symptoms with ordinary physical activity, Class III patients experience greater limitation in activity than described in this scenario. The client in this case only has slight limitation with ordinary activity, so Class III does not apply.

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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

A patient taking Digoxin is experiencing severe bradycardia, nausea and vomiting. A lab draw shows that their Digoxin level is 4 ng/mi (0.8-2.0 ng/ml). What management does the nurse anticipate the physician to order? Select all that apply.

Correct Answer is ["A"]

Explanation

The nurse is assessing a client who is diagnosed with heart failure and reports slight limitation of physical activity, is comfortable at rest but ordinary physical activity causes symptoms. What heart failure classification does this patient fall under?

Correct Answer is A

Explanation

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