Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is conducting a home health visit for an older adult client who lives with family members. The nurse notices that the client has multiple unusual bruises, and, based on several other factors, the nurse suspects that the client has been physically abused. Which of the following actions should the nurse take first?
A. Check the bruises at the next visit to the client's home.
Checking the bruises at the next visit may delay necessary intervention. If abuse is suspected, immediate action, such as reporting, is essential to protect the client.
B. Follow the agency's guidelines for reporting suspected abuse.
Following the agency's guidelines for reporting suspected abuse is the priority when abuse is suspected. Reporting abuse to the appropriate authorities, such as adult protective services or law enforcement, is crucial to ensure the safety and well-being of the older adult.
C. Institute more frequent visits to the client's home.
Instituting more frequent visits to the client's home might be part of a safety plan, but it should not be the first action. Reporting suspected abuse is the priority to involve the appropriate authorities.
D. Arrange referral for family therapy to deal with home stressors.
Arranging a referral for family therapy is not the first step in suspected elder abuse. Safety and protection of the older adult take precedence. Once the immediate safety concerns are addressed, additional interventions, such as family therapy, may be considered.
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Full Explanation
A. Checking the bruises at the next visit may delay necessary intervention. If abuse is suspected, immediate action, such as reporting, is essential to protect the client.
B. Following the agency's guidelines for reporting suspected abuse is the priority when abuse is suspected. Reporting abuse to the appropriate authorities, such as adult protective services or law enforcement, is crucial to ensure the safety and well-being of the older adult.
C. Instituting more frequent visits to the client's home might be part of a safety plan, but it should not be the first action. Reporting suspected abuse is the priority to involve the appropriate authorities.
D. Arranging a referral for family therapy is not the first step in suspected elder abuse. Safety and protection of the older adult take precedence. Once the immediate safety concerns are addressed, additional interventions, such as family therapy, may be considered.
Similar Questions
A nurse is collecting data from a client admitted to an inpatient mental health unit and has a new prescription for disulfiram (Antabuse). Which of the following information is most important for the nurse to obtain before administering this medication?
A. History of kidney disease
History of kidney disease is not as critical for disulfiram administration. The primary concern is related to hepatic metabolism.
B. When the client last drank alcohol
When the client last drank alcohol is relevant information, but it is not the most critical factor to consider before administering disulfiram. The primary mechanism of disulfiram is to inhibit the breakdown of acetaldehyde, leading to an unpleasant reaction if alcohol is consumed, regardless of when the client last drank.
C. If the client has taken disulfiram before
Whether the client has taken disulfiram before is important information, but it does not take precedence over the assessment of liver function. The history of liver disease is more directly related to the potential risks and adverse effects associated with disulfiram use.
D. History of liver disease
History of liver disease is crucial to assess before administering disulfiram because disulfiram is metabolized in the liver. Patients with a history of liver disease may have impaired liver function, and the medication may not be well-tolerated or could exacerbate existing liver issues.
Full Explanation
A. History of kidney disease is not as critical for disulfiram administration. The primary concern is related to hepatic metabolism.
B. When the client last drank alcohol is relevant information, but it is not the most critical factor to consider before administering disulfiram. The primary mechanism of disulfiram is to inhibit the breakdown of acetaldehyde, leading to an unpleasant reaction if alcohol is consumed, regardless of when the client last drank.
C. Whether the client has taken disulfiram before is important information, but it does not take precedence over the assessment of liver function. The history of liver disease is more directly related to the potential risks and adverse effects associated with disulfiram use.
D. History of liver disease is crucial to assess before administering disulfiram because disulfiram is metabolized in the liver. Patients with a history of liver disease may have impaired liver function, and the medication may not be well-tolerated or could exacerbate existing liver issues.
A nurse is caring for a client who has been brought to the emergency department and is experiencing acute fentanyl toxicity. The nurse should expect to observe which of the following adverse effects in this client?
A. Elevated heart rate
Elevated heart rate is not a typical sign of opioid toxicity. Opioids usually have a depressant effect on the cardiovascular system, leading to bradycardia.
B. Hypertension
Hypertension is not a typical effect of opioid toxicity. Opioids often cause hypotension due to vasodilation.
C. Pupilary dution
Pupillary constriction (miosis). Acute fentanyl toxicity is associated with opioid overdose, and opioids typically cause miosis (constriction of the pupils). Other common symptoms of opioid toxicity include respiratory depression, sedation, and potentially unconsciousness.
D. Tachypnea
Tachypnea is not a typical sign of opioid toxicity. Opioids tend to depress the respiratory system, leading to respiratory depression and potentially hypoventilation.
Full Explanation
A. Elevated heart rate is not a typical sign of opioid toxicity. Opioids usually have a depressant effect on the cardiovascular system, leading to bradycardia.
B. Hypertension is not a typical effect of opioid toxicity. Opioids often cause hypotension due to vasodilation.
C. Pupillary constriction (miosis).
Acute fentanyl toxicity is associated with opioid overdose, and opioids typically cause miosis (constriction of the pupils). Other common symptoms of opioid toxicity include respiratory depression, sedation, and potentially unconsciousness.
D. Tachypnea is not a typical sign of opioid toxicity. Opioids tend to depress the respiratory system, leading to respiratory depression and potentially hypoventilation.
A nurse is caring for a client on an acute care mental health unit who was involuntarily admitted for 72 hr after attacking a neighbor. To keep the client in the hospital when the initial time to hold the client expires, which of the following must be determined?
A. Whether the client is a danger to herself or others.
The criteria for involuntary commitment typically involve assessing whether the individual presents a danger to themselves or others. If the client continues to pose a significant risk of harm to themselves or others, the involuntary hold may be extended.
B. Whether the client is unwilling to accept that treatment is needed.
Whether the client is unwilling to accept that treatment is needed is relevant to the overall treatment plan, but it may not be the primary criterion for involuntary commitment. The focus is often on the immediate risk of harm.
C. Whether the client is financially incapable of paying for prescribed medications.
Whether the client is financially incapable of paying for prescribed medications is not typically a consideration in the decision to extend an involuntary hold. The decision is primarily based on the risk of harm to the client or others.
D. Whether the client is unable to make arrangements to stay with someone
Whether the client is unable to make arrangements to stay with someone is not a primary criterion for involuntary commitment. The decision is based on the assessment of the client's immediate danger to themselves or others.
Full Explanation
A. The criteria for involuntary commitment typically involve assessing whether the individual presents a danger to themselves or others. If the client continues to pose a significant risk of harm to themselves or others, the involuntary hold may be extended.
B. Whether the client is unwilling to accept that treatment is needed is relevant to the overall treatment plan, but it may not be the primary criterion for involuntary commitment. The focus is often on the immediate risk of harm.
C. Whether the client is financially incapable of paying for prescribed medications is not typically a consideration in the decision to extend an involuntary hold. The decision is primarily based on the risk of harm to the client or others.
D. Whether the client is unable to make arrangements to stay with someone is not a primary criterion for involuntary commitment. The decision is based on the assessment of the client's immediate danger to themselves or others.