Nokea
The nurse teaches a group of nursing students about elder abuse. Which older adult client does the nurse list as most likely to be a victim of abuse?
- A. A male diagnosed with moderate hypertension.
- B. A male with newly diagnosed cataracts.
- C. A female with advanced Parkinson disease.
- D. A female diagnosed with early stage Lyme disease.
Correct Answer: C
Rationale: Clients with advanced Parkinson disease are at higher risk for abuse due to increased dependency, physical limitations, and potential cognitive impairments, making them vulnerable to neglect or mistreatment. Other conditions listed are less likely to increase vulnerability to the same extent.
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A client is telling the nurse about his perception of his thought patterns. Which of the following statements by the client would validate the diagnosis of bipolar disorder?
- A. Sometimes I'm ready to take on the world, but other times I'm too tired to get out of bed.
- B. I need to check and then recheck all the kitchen appliances several times to make sure they are off before I feel comfortable leaving my home.
- C. My neighbors hold sacrificial rites in their backyard.
- D. I keep on patrol all night so the enemy won't invade my home and hurt me or my family.
Correct Answer: A
Rationale: This statement describes mood swings between mania and depression, characteristic of bipolar disorder.
An older client is brought to the emergency department by a family member with whom the client lives. The nurse observes that the client has poor hygiene, contractures, and pressure ulcers on the sacrum, the scapula, and the heels. Based on the nurse's assessment data, the client is suspected of which form of victimization?
- A. Sexual abuse
- B. Physical abuse
- C. Emotional abuse
- D. Psychological abuse
Correct Answer: B
Rationale: Victimization in a family can take many forms. When analyzing a specific client situation, it is important to understand which form of abuse is being considered. Physical abuse can take the form of battering (hitting, slapping, striking), or it can be more subtle, such as neglect (the failure to meet basic needs). Sexual abuse can involve unwanted sexual remarks, sexual advances, and physical sexual acts. Emotional and psychological abuse can involve inflicting verbal statements that cause mental anguish or alienation of the victim.
A nurse on the mental health unit is preparing a presentation on suicide for a group of student nurses. Which information would be included in this presentation? Select all that apply.
- A. Chronic pain or serious, disabling illness has little to no effect on suicide risk.
- B. Hispanic Americans attempt suicide at a greater rate than whites or African Americans.
- C. Suicide risk declines sharply once antidepressant medication has been taken for a few weeks.
- D. White males over the age of 80 are at the greatest risk among all age, race, and gender groups.
- E. Threatened suicide and/or gestures should be taken seriously and handled by trained professionals.
Correct Answer: D,E
Rationale: Chronic pain and serious illness increase suicide risk, making A incorrect. Data shows Hispanic Americans have lower suicide rates than whites, making B incorrect. Antidepressants may initially increase risk, making C incorrect. White males over 80 have the highest suicide rates, and all threats should be taken seriously, making D and E correct.
The nurse is admitting a client with schizophrenia. The client is extremely socially withdrawn, is unable to perform activities of daily living, has an inappropriate affect, and has grimacing mannerisms. The nurse understands that this client is experiencing which type of schizophrenia?
- A. residual schizophrenia
- B. paranoid schizophrenia
- C. catatonic schizophrenia
- D. disorganized schizophrenia
- E. undifferentiated schizophrenia
Correct Answer: D
Rationale: Disorganized schizophrenia is characterized by inappropriate affect, social withdrawal, grimacing, and impaired daily functioning.
A pregnant client comes into the prenatal clinic accompanied by her spouse. The spouse states they were in a car accident and his wife's abdomen hit the steering wheel. The nurse observes the client wringing her hands and not making eye contact. The client's record shows two recently missed prenatal appointments. Which action does the nurse take?
- A. Make eye contact with the client and ask about the accident.
- B. Accompany the client into the restroom to obtain a urine sample.
- C. Ask the husband if the wife had been drinking alcohol.
- D. Escort the couple to an examining room to await the health care provider.
Correct Answer: D
Rationale: Escorting the couple to an examining room prioritizes a safe, private assessment of the client’s condition post-accident, especially given signs of possible abuse (missed appointments, anxiety). Direct questioning or accusations may escalate tension, and a urine sample is not the priority.