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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.
- B. Institute more frequent visits to the client's home.
- C. Follow the agency's guidelines for reporting suspected abuse.
- D. Arrange referral for family therapy to deal with home stressors.
Correct Answer: C
Rationale: Delaying action by checking bruises later doesn’t address immediate safety. More frequent visits monitor but don’t act on the suspicion promptly. Following agency guidelines for reporting suspected abuse ensures the client’s safety first, as it’s the nurse’s legal and ethical duty. Therapy may help later but isn’t the first step without ensuring safety.
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A nurse in an assisted-living facility is caring for a client who is in early stages of dementia. The client has been oriented to name and place and is usually cooperative. Which of the following nursing actions is appropriate if the client refuses to take morning medications?
- A. Notify the charge nurse of the need for evaluation of the client's level of competence.
- B. Ask the client to express her reasons for refusing the morning medications and document the event.
- C. Crush the pills, if not contraindicated, and hide them in the client's applesauce.
- D. Try to talk the client into adherence by telling her the possible implications of missing a dose.
Correct Answer: B
Rationale: Competence evaluation follows understanding refusal. Asking reasons respects autonomy and informs care. Crushing pills without consent is unethical and risky. Coercion dismisses client rights; understanding is better.
A client with generalized anxiety disorder (GAD) is prescribed buspirone (BuSpar). Which information regarding side effects should be given to the client?
- A. The medication may cause cardiac arrest.
- B. Drink adequate amounts of fluid to prevent constipation
- C. The medication will not affect your vision.
- D. The risk of sedation is increased with this medication.
Correct Answer: B
Rationale: Cardiac arrest is not a common side effect of buspirone; it’s a rare and extreme outcome not typically associated with this medication. Buspirone can cause gastrointestinal side effects like constipation, so advising the client to drink adequate fluids helps mitigate this risk and supports overall health. There is no evidence that buspirone significantly affects vision as a common side effect, but this isn’t the most critical information to share. Buspirone is less sedating compared to other anxiolytics like benzodiazepines, so warning about increased sedation would be inaccurate.
A client is given the diagnosis of generalized anxiety disorder and is prescribed a benzodiazepine. The client should be instructed on which of the following?
- A. Monthly laboratory tests are needed to monitor drug level.
- B. Foods that contain tyramine should be avoided
- C. Benzodiazepines do not cause physical dependence.
- D. Benzodiazepines and alcohol can be dangerous
Correct Answer: D
Rationale: Lab tests aren’t routine for benzodiazepines. Tyramine avoidance applies to MAOIs, not benzodiazepines. Benzodiazepines can cause dependence, so that’s false. Combining benzodiazepines with alcohol increases CNS depression, posing risks like respiratory failure, making it critical to instruct the client on this danger.
An older adult is given the diagnosis of depression and is started on medication. Which group of medications would be appropriate for the depressed older adult?
- A. Selective serotonin reuptake inhibitors (SSRIs)
- B. Benzodiazepines
- C. Hypnotics
- D. Monoamine oxidase inhibitors
Correct Answer: A
Rationale: SSRIs are often the first-line treatment for depression in older adults due to their favorable side effect profile, including lower risk of sedation and falls compared to other options. Benzodiazepines are not typically used for depression as they treat anxiety and can increase the risk of falls and confusion in older adults. Hypnotics are used for sleep issues, not as antidepressants, and don’t address the core symptoms of depression. Monoamine oxidase inhibitors are effective but often reserved for cases where other treatments fail due to their dietary restrictions and potential for serious side effects.
For several days, an elderly client becomes confused and agitated after supper. This is an example of which of the following?
- A. Sundown syndrome
- B. Dementia
- C. Age-associated memory impairment
- D. Delirium
Correct Answer: A
Rationale: Sundown syndrome is increased confusion and agitation in the evening, matching the pattern. Dementia is broader and not time-specific. Age-associated memory impairment is mild and doesn’t include agitation. Delirium is acute and not tied to a daily cycle.