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: 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.

A. Abdominal pain B. Urticaria of the arms C. Persistent nasal drainage D. Pain during urination

Correct Answer is C

Explanation

Choice A reason: Abdominal pain is not a typical complication of hypophysectomy and is less urgent compared to other potential complications.

Choice B reason: Urticaria (hives) of the arms can indicate an allergic reaction but is not directly related to the surgery. It requires attention but is not the most critical finding.

Choice C reason: Persistent nasal drainage following hypophysectomy could indicate a cerebrospinal fluid (CSF) leak, which is a serious complication. CSF leaks require immediate medical attention to prevent meningitis and other complications.

Choice D reason: Pain during urination is not directly related to the hypophysectomy and is less urgent compared to other potential complications.

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Naxlex Comprehensive Predictor Exams

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

A nurse is monitoring a client post-hypophysectomy. Which assessment finding is most important to report to the health care provider?

Correct Answer is C

Explanation

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 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?

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

During an emergency code situation, a primary healthcare provider about to defibrillate a client diagnosed with ventricular fibrillation says in a loud voice, "CLEAR!" Which action should the nurse implement immediately?

A client diagnosed with acute kidney injury has an elevated blood urea nitrogen (BUN) and is experiencing difficulty remembering information. Which interventions should the nurse implement when communicating with this client? (Select all that apply)

A nurse is providing education for a client who has glaucoma. Which statement should the nurse include in the teaching?

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: