A client diagnosed with Alzheimer's Disorder has impairments of memory and judgement and is incapable of performing activities of daily living. Which nursing intervention should take priority?

Assist the client with bathing and toileting.

Design a bulletin board to represent the current season.

Present evidence of objective reality to improve cognition.

Label the door to the client's room with name and number.

Answer and Explanation

The Correct Answer is A

a. Assist the client with bathing and toileting. This intervention addresses the client's immediate and essential needs. Ensuring basic hygiene and toileting are crucial for maintaining the client's health, dignity, and comfort. Assisting with activities of daily living (ADLs) is a priority for clients who are unable to perform these tasks independently.
b. Design a bulletin board to represent the current season. While this can help with orientation and provide a sense of time and place, it is not as critical as addressing the client's basic physical needs.
c. Present evidence of objective reality to improve cognition. Reality orientation can be beneficial, but it is not a priority intervention compared to meeting the client's immediate physical needs.
d. Label the door to the client's room with name and number. This helps with orientation and independence but is less critical than ensuring the client’s hygiene and toileting needs are met.

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Correct Answer is ["B","C","D"]

Explanation

a. time of day. The time of day is not a significant factor in determining whether a situation will be perceived as a crisis.
b. client's perception of the event. This is correct because an individual's perception of an event greatly influences whether it is experienced as a crisis.
c. availability of adequate coping mechanisms. This is correct because having effective coping mechanisms can mitigate the impact of a stressful situation and prevent it from becoming a crisis.
d. availability of supports. This is correct because having a supportive network can help individuals manage stress and reduce the likelihood of a crisis.
e. location of a treatment centre. While access to treatment is important, the immediate experience of a crisis is more influenced by perception, coping mechanisms, and support systems than the location of a treatment centre.

A. leave the client alone to work out the problem, then tell the physician about the incident. B. tell the client to return to room and write their thoughts in a journal. C. give the prescribed flumazenil 5 mg IM D. remain with the client and ensure safety.

Correct Answer is D

Explanation

a. Leave the client alone: Leaving the client alone during a flashback could be dangerous.
b. Journaling: While journaling can be helpful for managing PTSD, it's not appropriate during a crisis situation.
c. Flumazenil: Flumazenil is used to reverse benzodiazepine overdose, not for PTSD flashbacks.
d. remain with the client and ensure safety: A PTSD flashback can be overwhelming and lead to self-harm or aggression. The nurse's priority is to ensure the client's safety and the safety of others.

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A client diagnosed with Alzheimer's Disorder has impairments of memory and judgement and is incapable of performing activities of daily living. Which nursing intervention should take priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse understands that whether or not a client experiences crisis as a result of a stressful situation depends on the: (SELECT ALL THAT APPLY)

Correct Answer is ["B","C","D"]

Explanation

A client, who was diagnosed with Post Traumatic Stress Disorder (PTSD), is now experiencing flashbacks and is displaying irritable behavior. The nurse would:

Correct Answer is D

Explanation

After having one conversation with a female nurse, a young male client asks the nurse for her phone number. He says that he would like to date her. Which of the following responses would be most appropriate?

What should be the priority nursing action during the orientation (introductory) phase of the nurse-client relationship?

A client diagnosed with schizophrenia, on an inpatient unit, approaches a nurse, stating, "Someone took my dinner! People need to respect others, and you need to do something about this now!" Which response by the nurse is guided by the basic assumption of the therapeutic milieu?

Which of the following would be the best nursing action for a client who is having a panic attack?

The nurse understands that which medication has been used with some success in clients diagnosed with anorexia nervosa along with depression?

The nurse is assessing a client diagnosed with schizophrenia, who has been prescribed Haloperidol for the past year. On assessment, the nurse notices that the client is demonstrating bizarre facial and tongue movements. What is the priority nursing intervention?

A client diagnosed with vascular neurocognitive disorder (NCD) is discharged to home under the care of his wife. Which information should cause the nurse to question the client's safety?

A new nurse orientee asks why a client admitted to the psychiatric unit is placed in seclusion. The nurse precepting the new nurse explains that which of the following is a benefit of seclusion?