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 C

Explanation

Choice A reason: Telling the client that they are hospitalized due to a heart attack when it is not the case can cause unnecessary anxiety and fear. It is important to provide accurate information and reassurance.

Choice B reason: Stating that it will never happen again is unrealistic and provides false reassurance. It is important to focus on managing the client's condition and reducing the risk of future episodes.

Choice C reason: Explaining that the client did not have a heart attack but emphasizing the importance of monitoring and managing chest pain provides accurate information and reassurance. It helps reduce the client's anxiety and provides a clear plan of action.

Choice D reason: Saying it is normal to feel chest pain without further explanation can cause confusion and anxiety. It is important to clarify that chest pain needs to be monitored and managed to prevent complications.

A. Prolonged bleeding B. Dry mucous membrane C. Peaked T-waves D. Polyuria

Correct Answer is C

Explanation

Choice A reason: Prolonged bleeding is not a direct indicator of hyperkalemia. It is more commonly associated with coagulation disorders or conditions affecting blood clotting.

Choice B reason: Dry mucous membranes are more indicative of dehydration rather than hyperkalemia. Dehydration can result from a variety of conditions but is not specific to high potassium levels.

Choice C reason: Peaked T-waves on an electrocardiogram (ECG) are a classic sign of hyperkalemia. Elevated potassium levels affect the cardiac conduction system, leading to characteristic changes in the ECG, such as tall, peaked T-waves, widened QRS complexes, and flattened P-waves.

Choice D reason: Polyuria (excessive urination) is not typically associated with hyperkalemia. It is more commonly seen in conditions like diabetes mellitus or diabetes insipidus.

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Naxlex Comprehensive Predictor Exams

A client diagnosed with angina pectoris appears to be very anxious and states, "So I had a heart attack, right?" Which response should the nurse make to the client?

Correct Answer is C

Explanation

The nurse is assessing a client diagnosed with Addison's disease for signs of hyperkalemia. What should the nurse observe with this electrolyte imbalance?

Correct Answer is C

Explanation

A nurse is caring for an older adult client who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take?

The home care nurse is preparing to visit a client diagnosed with Meniere's disease. The nurse reviews the primary health care provider's prescriptions and expects to educate the client on which dietary measure?

There are several factors that may cause a patient to present with sinus bradycardia. What are some causes of sinus bradycardia? (Select all that apply)

A nurse is caring for a child who has otitis media with effusion. The nurse should identify that which of the following manifestations indicates a tympanic membrane rupture?

A client newly diagnosed with angina pectoris has taken two sublingual nitroglycerin tablets for chest pain. The chest pain is relieved, but the client now reports a headache. The nurse interprets that this most likely represents which response?

The nurse realizes that which clients are at risk for intra-renal injury? (Select all that apply)

A client is admitted to the hospital with a myasthenic crisis. The nurse should anticipate which potential precipitating factors for this event?

A nurse in the med-surgical ICU is assessing a client in the oliguric phase of acute kidney injury. Which of the following findings should the nurse expect?