A nurse is caring for a client who has Alzheimer's disease. The nurse discovers the client entering the room of another client, who becomes upset and frightened. Which of the following actions should the nurse take?
Attempt to determine what the client was looking for.
Reprimand the client for invading the other client's privacy.
Explain the client's Alzheimer's diagnosis to the frightened client.
Ask the client to apologize for his behavior.
The Correct Answer is A
A. Attempt to determine what the client was looking for is the best response. In Alzheimer's disease, clients may exhibit wandering behavior and confusion, often seeking something familiar or trying to meet an unmet need. Understanding what the client was looking for can help address their needs and prevent further agitation.
B. Reprimanding the client for invading the other client's privacy is not appropriate. Clients with Alzheimer's disease may not be aware of the concept of privacy or the impact of their actions. Reprimanding can cause distress and confusion.
C. Explaining the client's Alzheimer's diagnosis to the frightened client may help provide understanding, but it does not address the immediate concern of calming the frightened client. The focus should be on managing the behavior in the moment.
D. Asking the client to apologize for his behavior is not appropriate, as the client may not have the cognitive ability to understand or remember the need to apologize. This could cause frustration and confusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The postictal phase refers to the period immediately following a seizure when the client is often drowsy, confused, or difficult to arouse. This phase can last for several minutes to hours, depending on the individual.
B. Absence seizures are brief, generalized seizures characterized by staring and loss of awareness, often without a postictal phase.
C. The aura phase refers to the sensory warning or symptoms that precede a seizure, not the post-seizure state.
D. Automatisms are involuntary, repetitive movements (such as lip smacking or hand wringing) that can occur during a seizure, but they do not describe the postictal state.
Correct Answer is B
Explanation
A. 700: This is incorrect, check the calculation in choice D rationale
B. 660: This is incorrect, check the calculation in choice D rationale
C. 900: This is incorrect, check the calculation in choice D rationale
D. To calculate the total intake, we need to convert all fluid measurements to milliliters (mL) and then add them together:
- Coffee: 240 mL
- Milk: 60 mL
- Apple juice: 120 mL
- Broth: 8 oz = 240 mL (1 oz = 30 mL)
- Water: 10 oz = 300 mL (1 oz = 30 mL)
Now, add them together:
240 mL (coffee) + 60 mL (milk) + 120 mL (apple juice) + 240 mL (broth) + 300 mL (water) = 960 mL.
Thus, the total intake is 960 mL, which corresponds to D.
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