A home health nurse is visiting a client who has advanced Alzheimer's disease. The client's partner states, "I miss being able to go places with my friends." Which of the following is an appropriate response by the nurse?
"We can discuss this when you're not feeling overwhelmed."
"I understand how you feel. I've had a relative go through the same thing."
"Have you tried taking your partner with you when you go out?"
"Tell me more about your expectations."
The Correct Answer is D
Choice A Reason:
"We can discuss this when you're not feeling overwhelmed." Is incorrect. This response acknowledges the partner's feelings but doesn't directly address their concern about missing social outings. It offers to revisit the topic later, which might be helpful, but it doesn't provide immediate support or suggestions.
Choice B Reason:
"I understand how you feel. I've had a relative go through the same thing." Is incorrect. While expressing empathy is essential, comparing experiences might inadvertently minimize the partner's feelings. Each situation is unique, and the partner might need specific advice or support tailored to their circumstances.
Choice C Reason:
"Have you tried taking your partner with you when you go out?" is incorrect. This response suggests a potential solution by proposing involving the client with Alzheimer's in social outings. However, in advanced stages, this might not always be feasible or suitable due to the nature of the condition. It's essential to be sensitive to the client's needs and abilities.
Choice D Reason:
"Tell me more about your expectations." Is correct. This response invites the partner to share more about their feelings and desires without assuming a solution. It opens a dialogue to understand the partner's concerns and expectations better, allowing the nurse to offer appropriate support or guidance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Measuring the intake and output of a client who has received furosemide is correct. This task involves recording and measuring fluid intake and output, which is typically within the scope of practice for assistive personnel. It requires accurate documentation and doesn't involve making clinical judgments.
Choice B Reason:
Reinforcing teaching with a client about crutch-gait walking is incorrect. Teaching and instructing clients about specific medical procedures or techniques usually require specialized knowledge and assessment skills, typically within the nurse's scope of practice.
Choice C Reason:
Checking a client's peripheral IV site for redness or swelling is incorrect. Assessing for redness or swelling at an IV site involves clinical judgment and assessment skills to identify potential complications. This task is better suited for a licensed nurse who can interpret findings and take appropriate action if needed.
Choice D Reason:
Assessing the pain level of a client who has received acetaminophen is incorrect. Assessing pain levels involves subjective interpretation and understanding of pain scales, which generally falls under the scope of licensed healthcare providers who can evaluate and manage pain interventions based on assessments.
Correct Answer is ["C","D","E"]
Explanation
Choice A Reason :
Increased peripheral circulation is incorrect. As people age, changes in the cardiovascular system can occur, but increased peripheral circulation isn't a common physiological change. In fact, aging might lead to reduced elasticity in blood vessels, potentially resulting in decreased circulation to some areas.
Choice B Reason:
Increased saliva production is incorrect: Saliva production doesn't usually increase with age. Instead, certain medications, medical conditions, or treatments might impact saliva production. Aging itself doesn't commonly cause an increase in saliva production; in fact, it can decrease due to changes in salivary glands.
Choice C Reason:
Increased constipation is correct. As individuals age, there can be changes in gastrointestinal motility and muscle tone, which can contribute to an increased likelihood of constipation.
Choice D Reason:
Decreased muscle mass is correct. Aging often leads to a natural decline in muscle mass and strength, known as sarcopenia, which can affect mobility and overall physical function.
Choice E Reason:
Decreased cough reflex is correct. With aging, the cough reflex might become less sensitive or effective, which can impact the ability to clear the airways efficiently.
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