A client with end-stage Alzheimer's disease is brought to the clinic by the caregiver for an appointment with the healthcare provider. The caregiver speaks privately to the nurse about not sleeping well at night and experiencing frequent periods of crying. Which intervention should the nurse implement?

Suggest social services be contacted to find a respite care facility for the client.

Propose the extended family could return to the area to help provide assistance.

Tell the caregiver to consider hiring a private duty nurse for time to be away.

Advise to have a case management evaluation of the client's home environment.

Answer and Explanation

The Correct Answer is A

A. Suggest social services be contacted to find a respite care facility for the client.
This is the correct answer. Respite care provides temporary relief for primary caregivers, offering them a break from the daily routine and stress of caregiving. This can be crucial in preventing caregiver burnout and addressing the caregiver's emotional and physical health needs.

B. Propose the extended family could return to the area to help provide assistance.
While involving extended family might be helpful, it is not always feasible or the most immediate solution. The caregiver needs structured, reliable support, which can be effectively provided through respite care services.

C. Tell the caregiver to consider hiring a private duty nurse for time to be away.
Hiring a private duty nurse can be expensive and might not be a viable option for all families. While it could be beneficial, it may not be the best initial suggestion given the caregiver's current stress and emotional state.

D. Advise to have a case management evaluation of the client's home environment.
While a case management evaluation might help in assessing and improving the home environment and care plan, it does not directly address the immediate need for relief and support for the caregiver's emotional and physical well-being.

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Correct Answer is B

Explanation

A. Provide only distilled water. Providing only distilled water is not appropriate in this situation.
The client's weight gain and electrolyte imbalance indicate the need for careful monitoring and intervention, but restricting fluid intake to distilled water alone may not address the underlying issues adequately.
B. Document abdominal girth. Documenting abdominal girth is important to assess for signs of ascites, which can occur in hepatic failure. A sudden weight gain and elevated blood pressure may indicate fluid retention, and documenting abdominal girth can provide additional information about fluid accumulation in the abdomen.
C. Offer a high protein diet. While nutritional support is important for clients with hepatic failure, offering a high protein diet may not be appropriate if the client has an electrolyte imbalance. Protein intake should be balanced and monitored carefully to avoid exacerbating the imbalance.
D. Use a cushion when sitting. Using a cushion when sitting may be beneficial for comfort, but it does not directly address the identified issues of electrolyte imbalance, elevated blood pressure, and weight gain. The priority is to assess and address these concerns through appropriate
interventions such as documenting abdominal girth and addressing fluid retention.

A. Clamp the chest tube immediately with a plastic clamp. B. Apply an occlusive dressing over the chest tube site. C. Ensure the chest tubing is not kinked or hanging low. D. Reinforce the chest tube connection to the container with tape.

Correct Answer is C

Explanation

A. Clamp the chest tube immediately with a plastic clamp. Clamping the chest tube can lead to tension pneumothorax, which is a life-threatening complication. It should never be done unless specifically instructed by a healthcare provider.
B. Apply an occlusive dressing over the chest tube site. This action is not indicated in this situation and could interfere with drainage.
C. Ensure the chest tubing is not kinked or hanging low. This is the correct intervention as a kinked or dependent chest tube can impede drainage, leading to respiratory distress.
D. Reinforce the chest tube connection to the container with tape. While ensuring the chest tube connection is secure is important, it is not the priority in this situation where the client is experiencing sudden shortness of breath.

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Naxlex Comprehensive Predictor Exams

The nurse identifies an electrolyte imbalance, an elevated blood pressure, and a weight gain of 4.4 lbs (2 kg) in 24 hours for a client with hepatic failure. Which intervention should the nurse include in the plan of care?

Correct Answer is B

Explanation

A client with a right hemopneumothorax has a chest tube connected to suction. While turning to the left side, the client becomes suddenly short of breath and anxious. Which intervention should the nurse implement?

Correct Answer is C

Explanation

The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. Which action should the nurse implement immediately?

The nurse is monitoring a client with Cushing's disease in the postanesthesia care unit (PACU) after a hypophysectomy. Which intervention is most important for the nurse to include in the client's plan of care?

The nurse is providing discharge instructions to a client with gout in the left great toe who received a prescription for prednisone 30 mg by mouth to be administered each day. Which symptom should the nurse explain is most important for the client to report to the healthcare provider?

Exhibits The nurse should place the client in a position to promote

Exhibits For each statement, click to specify whether the statement is consistent with iron deficiency anemia, vitamin B12 deficient anemia, or folic acid deficient anemia. Each row must have at least one, but may have more than one, response option selected.