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) A corticosteroid such as fluticasone:
While corticosteroids, such as fluticasone, are effective for managing chronic asthma and preventing inflammation over time, they are not the first-line treatment during an acute asthma attack. Corticosteroids are typically used for long-term control and maintenance therapy, not for rapid relief of symptoms in an acute exacerbation. Immediate relief is needed in acute situations, which corticosteroids alone do not provide.

B) A long-acting beta 2 agonist such as salmeterol:
Long-acting beta-2 agonists (LABAs), such as salmeterol, are used for maintenance therapy to prevent asthma attacks and should not be used for the immediate treatment of an acute asthma exacerbation. They take longer to start working, and their role is to provide prolonged bronchodilation over time, not to relieve sudden bronchoconstriction.

C) A short-acting beta 2 agonist such as albuterol:
During an acute asthma attack, the immediate goal is to relieve bronchoconstriction and improve airflow. Short-acting beta-2 agonists like albuterol are the first-line treatment because they quickly relax the smooth muscles of the airways, leading to bronchodilation. Albuterol works within minutes, providing rapid relief from the symptoms of wheezing, shortness of breath, and chest tightness.

D) Methylxanthines such as Theophylline:
Methylxanthines (e.g., theophylline) were once used for asthma management but are no longer considered the first-line treatment for acute exacerbations due to their narrow therapeutic range and the potential for toxicity. While theophylline can provide bronchodilation, its onset of action is slower than that of beta-agonists like albuterol, and it is generally reserved for more chronic management of asthma or severe cases where other medications are not effective.

A. Unstable Supraventricular tachycardia B. Unstable Bradycardia C. Ventricular Fibrillation D. Ventricular tachycardia with NO pulse E. Unstable Atrial Flutter

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"C"}}

Explanation

Dysrhythmias	Transcutaneous Pacing	Defibrillation	Synchronized cardioversion
Unstable Supraventricular tachycardia			✔️
Unstable Bradycardia	✔️
Ventricular Fibrillation		✔️
Ventricular tachycardia with NO pulse		✔️
Unstable Atrial Flutter			✔️

Unstable Supraventricular Tachycardia: Synchronized Cardioversion

Unstable Bradycardia: Transcutaneous Pacing

Ventricular Fibrillation: Defibrillation

Ventricular Tachycardia with No Pulse: Defibrillation

Unstable Atrial Flutter: Synchronized Cardioversion

Rationales:

Unstable Supraventricular Tachycardia – Synchronized Cardioversion:

Synchronized cardioversion delivers a timed electrical shock to the heart during the R wave, avoiding the vulnerable T wave, which minimizes the risk of inducing ventricular fibrillation. This intervention is preferred for unstable SVT unresponsive to medications, as it restores normal sinus rhythm effectively.

Unstable Bradycardia – Transcutaneous Pacing:

Transcutaneous pacing provides electrical impulses to stimulate the heart when intrinsic conduction is insufficient. It is the recommended treatment for symptomatic bradycardia that does not respond to medications, ensuring adequate cardiac output while awaiting more definitive treatment.

Ventricular Fibrillation – Defibrillation:

Defibrillation delivers an unsynchronized shock to depolarize the entire myocardium, allowing the heart to reset and resume an organized rhythm. It is the first-line intervention for ventricular fibrillation, as the chaotic electrical activity makes the heart incapable of pumping blood.

Ventricular Tachycardia with No Pulse – Defibrillation:

Pulseless ventricular tachycardia requires defibrillation, as the rhythm is life-threatening and the absence of a pulse indicates the heart is not effectively pumping. This unsynchronized shock interrupts the abnormal rhythm, allowing normal sinus rhythm to potentially resume.

Unstable Atrial Flutter – Synchronized Cardioversion:

Synchronized cardioversion is used for unstable atrial flutter to restore sinus rhythm by delivering a precisely timed electrical shock. It is effective when pharmacological measures have not worked or are inappropriate, especially in cases of hemodynamic instability.

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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?

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Naxlex Comprehensive Predictor Exams

A client in the emergency room begins to experience an acute asthma attack. The nurse expects that which medication will be used as initial treatment?

Correct Answer is C

Explanation

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"C"}}

Explanation

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