While assessing an older adult client, the nurse notes that the client has old and new ecchymotic areas on the extremities and buttocks upon admission. The client states to the nurse in confidence that the family members frequently hit him. Which therapeutic statement should the nurse communicate in response?

Let's get these treated

I'll report this type of abuse

Call the emergency department

I'll keep this in confidence

Answer and Explanation

The Correct Answer is B

Choice A reason: While treating the injuries is important, addressing the root cause of abuse is crucial for the client's safety. Simply treating the injuries without addressing the abuse may allow the cycle of harm to continue.

Choice B reason: Reporting the abuse is a legal and ethical responsibility for healthcare providers. Ensuring the client's safety and providing necessary interventions to stop the abuse is paramount.

Choice C reason: Calling the emergency department is not the correct response. The nurse should follow the proper protocol for reporting abuse, which involves notifying social services or other relevant authorities.

Choice D reason: Keeping the information in confidence is not appropriate when dealing with abuse cases. The nurse must act to protect the client and report the abuse to prevent further harm.

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Correct Answer is A

Explanation

Choice A reason: Administering an antipyretic to reduce the fever and notifying the primary health care provider are the priority actions. A rapid rise in temperature in a client with multiple myeloma receiving chemotherapy could indicate a serious infection, which requires prompt medical attention.

Choice B reason: Assessing the color and content of the urine specimen for urinalysis is important but is not the immediate priority. The rapid rise in temperature is a more urgent concern.

Choice C reason: Noting the consistency of respiratory secretions and obtaining a specimen for culture is important but not the immediate priority. The primary concern is addressing the fever and notifying the healthcare provider.

Choice D reason: Comparing prior vital signs and continuing to monitor every hour is necessary but not the immediate priority. Immediate action is required to address the fever and potential infection.

A. A patient with a new-onset of confusion and restlessness. B. A patient who reports dizziness after receiving captopril (Capoten). C. A patient who requires oxygen via nasal cannula with saturations of 97%. D. A patient who has received digoxin and has a blood pressure (BP) of 100/56.

Correct Answer is A

Explanation

Choice A reason: A patient with a new-onset of confusion and restlessness is a priority because these symptoms could indicate a serious condition such as hypoxia, electrolyte imbalance, or a neurological event like a stroke. These changes in mental status need to be evaluated immediately to prevent further complications.

Choice B reason: Dizziness after receiving captopril (Capoten) can be a side effect of the medication due to its blood pressure-lowering effects. While it should be monitored, it is not as urgent as the new-onset confusion and restlessness seen in another patient.

Choice C reason: A patient requiring oxygen via nasal cannula with saturations of 97% is stable as the oxygen saturation is within normal limits. This patient does not need to be prioritized over others with more acute symptoms.

Choice D reason: A patient who has received digoxin and has a blood pressure of 100/56 should be monitored, especially for signs of digoxin toxicity. However, this situation is not as critical as the new-onset confusion and restlessness in another patient.

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Naxlex Comprehensive Predictor Exams

A client with multiple myeloma receiving chemotherapy has a temperature of 102.2 degrees Fahrenheit. The temperature was 99.2 degrees Fahrenheit six hours ago. The PRIORITY nursing intervention is to:

Correct Answer is A

Explanation

The night nurse in the cardiac ICU has just received a report on several patients. Which of the following clients should the nurse prioritize for rounds?

Correct Answer is A

Explanation

The nurse is teaching a client with newly diagnosed asthma. Which instructions should the nurse include to reduce the likelihood of an asthma attack? (Select all that apply)

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A nurse is discussing gout with a client concerned about developing the disorder. What should the nurse identify as risk factors for the disease? (Select all that apply)

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