A nurse in an acute care facility is providing teaching for the adult child of an older adult client who is admitted with a urinary tract infection and delirium. The client has been living independently at home. Which of the following statements by the adult child demonstrates the teaching has been effective?

"I should look into the possibility of long-term care for my father when he is discharged."

"I would like information about respite care for when my father is discharged."

"I expect that my father will no longer be confused when he is discharged."

"I will obtain a permanent identification bracelet for my father when he is discharged."

Answer and Explanation

The Correct Answer is C

Choice A reason: This statement reflects a misunderstanding of the situation. Delirium is an acute, reversible condition often triggered by infections such as urinary tract infections. Long-term care placement is not automatically indicated once delirium resolves, especially since the client was living independently prior to hospitalization. Planning for long-term care prematurely assumes permanent cognitive decline, which is not consistent with delirium’s clinical course.

Choice B reason: Respite care is designed to provide temporary relief for caregivers of individuals with chronic conditions or long-term care needs. Since the client was living independently before admission and delirium is expected to resolve after treatment of the infection, respite care is not necessary at this point. This statement suggests the adult child believes ongoing caregiver support will be required, which is inaccurate for this clinical scenario.

Choice C reason: This statement demonstrates accurate understanding. Delirium is characterized by acute onset of confusion, disorientation, and fluctuating mental status, often secondary to an underlying medical condition such as infection. Once the infection is treated and the acute illness resolves, the delirium typically subsides, and the client’s baseline cognitive function returns. Recognizing that the confusion is temporary and reversible shows that the teaching has been effective.

Choice D reason: Obtaining a permanent identification bracelet is more appropriate for clients with chronic, progressive cognitive disorders such as dementia or Alzheimer’s disease, where confusion and wandering are persistent risks. Since delirium is reversible and not a permanent condition, this intervention is unnecessary. This statement reflects a misunderstanding of the difference between delirium and dementia.

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Correct Answer is A

Explanation

Choice A reason: A residential rehabilitation program is the most appropriate referral for a client with severe hypertension who requires detoxification for alcohol use disorder. Residential programs provide 24-hour medical supervision, structured detoxification, and comprehensive support. This level of care is necessary to manage both the medical complications of hypertension and the risks associated with alcohol withdrawal, such as seizures or delirium tremens.

Choice B reason: Intensive outpatient therapy is beneficial for clients who are medically stable and can manage withdrawal symptoms safely outside of a hospital or residential setting. However, this client has severe hypertension and requires detoxification, which necessitates closer monitoring than outpatient care can provide.

Choice C reason: Alcoholics Anonymous is a peer-support group that provides ongoing recovery support but does not offer medical detoxification or structured treatment. While AA can be valuable after stabilization, it is not appropriate as the initial referral for a client requiring medical detox.

Choice D reason: A halfway house provides transitional living arrangements for individuals recovering from substance use disorders. It is useful after detoxification and initial treatment but does not provide the medical supervision or detox services needed at this stage.

A. Systematic desensitization B. Role Playing C. Biofeedback D. Cognitive restructuring

Correct Answer is B

Explanation

Choice A reason: Systematic desensitization is a behavioral therapy technique used to reduce phobias or anxiety by gradually exposing the client to the feared stimulus while teaching relaxation strategies. It does not involve acting out scenarios or practicing new behaviors in a group setting.

Choice B reason: Role playing is the correct answer because it involves acting out scenarios and practicing new behaviors in a safe environment. This technique allows clients to rehearse adaptive responses, gain confidence, and receive feedback. It is widely used in behavioral therapy and group education to promote skill acquisition and behavioral change.

Choice C reason: Biofeedback involves using monitoring devices to provide clients with information about physiological processes such as heart rate or muscle tension. Clients learn to control these processes voluntarily. While effective for stress reduction, it does not involve acting out scenarios or practicing interpersonal behaviors.

Choice D reason: Cognitive restructuring is a cognitive-behavioral technique focused on identifying and challenging distorted thoughts. It helps clients replace maladaptive thinking patterns with healthier ones. While important in therapy, it does not involve role enactment or practicing behaviors in scenarios.

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Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is preparing to discharge a client who has severe hypertension and requires detoxification for alcohol use disorder. The nurse should recommend a referral to which of the following resources?

Correct Answer is A

Explanation

A nurse is planning to teach a group of clients about techniques to change unwanted behaviors. Which of the following techniques is the nurse using when they act out different scenarios and has clients respond by practicing new behaviors?

Correct Answer is B

Explanation

A nurse is assisting in obtaining informed consent from a client who is scheduled for vagus nerve stimulation. Which of the following actions should the nurse take to act as a client advocate?

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A home health nurse is caring for a new client who has hoarding disorder that involves food. Which of the following actions should the nurse take first?

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A nurse in a mental health clinic is assessing a client who has dependent personality disorder. Which of the following findings should the nurse expect?

A nurse is providing information to a client who is seeking voluntary admission to a mental health facility. Which of the following information should the nurse include?

Upon re-evaluation of the client, which of the following findings indicate that a change to the client's treatment plan is indicated?

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