A nurse in a long-term care facility is caring for a client with dementia who is upset over not being able to find their spouse, who passed away years ago. Which of the following actions should the nurse take first?

Take the client for a walk and ask them to talk about their family

Administer alprazolam to decrease their anxiety

Administer olanzapine to decrease their agitation

Take the client to their room so they will not upset others

Answer and Explanation

The Correct Answer is A

Choice A reason: Engaging the client in a walk and family discussion uses therapeutic communication and redirection, common in dementia care. This non-pharmacological approach validates emotions, reduces distress, and promotes calmness by shifting focus to positive memories, aligning with person-centered care principles to address emotional needs first.

Choice B reason: Alprazolam, a benzodiazepine, reduces anxiety but carries risks like sedation and falls in dementia patients. Pharmacological interventions should be secondary to non-pharmacological approaches, as they may exacerbate confusion or dependency. Addressing emotional distress through engagement is preferred before considering medications for anxiety management.

Choice C reason: Olanzapine, an antipsychotic, is used for severe agitation or psychosis in dementia. It poses risks like sedation, extrapyramidal symptoms, and increased mortality in elderly patients. Non-pharmacological interventions, like redirection, are prioritized to manage emotional distress safely, reserving medications for when behavioral approaches fail.

Choice D reason: Isolating the client in their room may increase distress and agitation in dementia patients, as it does not address their emotional needs. Social isolation can worsen confusion and feelings of abandonment. Therapeutic engagement, such as redirection or validation, is more effective in calming the client and fostering trust.

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Correct Answer is A

Explanation

Choice A reason: Rebound tenderness at McBurney’s point (right lower quadrant) indicates peritoneal irritation, a hallmark of appendicitis. The inflamed appendix causes localized pain, exacerbated by pressure release due to peritoneal inflammation. This specific finding is highly suggestive of appendicitis, distinguishing it from other abdominal conditions.

Choice B reason: Left lower quadrant pain is not typical for appendicitis, which usually presents in the right lower quadrant due to the appendix’s anatomical location. Left-sided pain may suggest conditions like diverticulitis or colitis, but it does not align with the localized inflammation characteristic of appendicitis.

Choice C reason: High-pitched bowel sounds suggest increased peristalsis, as in early obstruction, but are not specific to appendicitis. Appendicitis may reduce bowel sounds due to peritoneal irritation. Rebound tenderness is a more direct indicator, as it reflects the localized inflammation and irritation of appendicitis.

Choice D reason: A soft, non-tender abdomen is inconsistent with appendicitis, which causes localized pain and tenderness due to inflammation. A non-tender abdomen suggests a normal or alternative condition, not appendicitis, where peritoneal irritation typically produces tenderness, especially at McBurney’s point, upon palpation or rebound.

A. Hypomagnesemia B. Hyponatremia C. Hyperchloremia D. Hypokalemia

Correct Answer is A

Explanation

Choice A reason: Hypomagnesemia, low magnesium (normal 1.7–2.2 mg/dL), is indicated by the 0.8 mEq/L value. Magnesium is vital for muscle, nerve, and cardiac function. Low levels can cause tremors, seizures, and arrhythmias. The other values (sodium, chloride, potassium) are within normal ranges, making hypomagnesemia the primary imbalance.

Choice B reason: Hyponatremia, low sodium (normal 135–145 mEq/L), is not indicated, as the sodium level is 140 mEq/L, within normal limits. Hyponatremia can cause neurological symptoms like confusion, but the lab values do not support this diagnosis, and magnesium imbalance is the clear abnormality.

Choice C reason: Hyperchloremia, high chloride (normal 98–106 mEq/L), is not present, as the chloride level is 107 mEq/L, just above normal and not clinically significant. Elevated chloride may occur in dehydration or renal issues, but the primary concern here is the significantly low magnesium level.

Choice D reason: Hypokalemia, low potassium (normal 3.5–5.0 mEq/L), is not indicated, as the potassium level is 3.6 mEq/L, within normal range. Hypokalemia causes muscle weakness and arrhythmias, but the lab values point to hypomagnesemia as the primary electrolyte imbalance in this case.

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A nurse in a long-term care facility is caring for a client with dementia who is upset over not being able to find their spouse, who passed away years ago. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is evaluating a client with suspected appendicitis. Which physical assessment finding is most indicative of this condition?

Correct Answer is A

Explanation

As the nurse assesses a client’s laboratory values, the following are noted: Sodium 140 mEq/L, Magnesium 0.8 mEq/L, Chloride 107 mEq/L, Potassium 3.6 mEq/L. What electrolyte imbalance is indicated?

Correct Answer is A

Explanation

As the nurse assesses a client’s laboratory values, the following are noted: Sodium 140 mEq/L, Magnesium 0.8 mEq/L, Chloride 107 mEq/L, Potassium 3.6 mEq/L. What electrolyte imbalance is indicated?

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indicate the nurse is addressing the affective domain of learning?

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