A nurse is caring for a client who has dementia due to Alzheimer's disease and was admitted to a long-term care facility following the death of her partner of 40 years. The client states, "I want to go home; my husband is waiting for me to cook dinner." Which of the following responses by the nurse is appropriate?

"This is a safer place for you to live."

"Your family said there is no one to care for you at home."

"This is where you live now."

"Tell me what you like to cook for dinner."

Answer and Explanation

The Correct Answer is D

A. "This is a safer place for you to live." While this response may be factual, it could be dismissive of the client's feelings. The client is expressing a desire to return home, and it's important to validate their emotions instead of immediately focusing on the safety of the current setting.

B. "Your family said there is no one to care for you at home." This response is not therapeutic and could be perceived as dismissive or defensive. The focus should be on empathizing with the client's feelings and acknowledging their emotional distress rather than explaining why they are in the facility.

C. "This is where you live now." Although this is true, this response can be blunt and dismissive. It doesn't acknowledge the client's emotional needs or provide comfort. It may lead the client to feel unheard or misunderstood.

D. "Tell me what you like to cook for dinner." This is the most appropriate response. It allows the nurse to engage with the client's feelings and encourage them to talk about a topic they enjoy, which can help reduce distress. It also provides an opportunity to redirect the client in a supportive and validating way, focusing on their memory and emotional needs rather than focusing on what they can't change.

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Correct Answer is B

Explanation

A. "This medication may increase your blood pressure." Risperidone typically does not cause an increase in blood pressure. In fact, it can cause orthostatic hypotension (a drop in blood pressure when standing), not an increase in blood pressure, so this statement is incorrect.

B. "Avoid becoming overheated while taking this medication. "Risperidone, like other antipsychotics, can impair the body’s ability to regulate temperature, increasing the risk of overheating or heatstroke, especially in hot weather or during physical exertion. Clients should be advised to avoid overheating.

C. "Flu-like symptoms are an expected adverse effect of this medication." Flu-like symptoms are not a common or expected side effect of risperidone. Common side effects include sedation, weight gain, and metabolic changes, but flu-like symptoms are not typical.

D. "Muscle twitches can occur the first few weeks while taking this medication." While risperidone can cause movement disorders such as tremors or muscle stiffness (extrapyramidal symptoms), muscle twitches are not a specific or common side effect that typically occurs in the first few weeks. This statement could cause unnecessary concern for the client.

A. "His favorite teacher committed suicide a few weeks ago." B. "He is very religious and attends services twice a week." C. "He spends much of his time with his two school friends." D. "He has slept 9 hours each night for the past 2 years."

Correct Answer is A

Explanation

A. "His favorite teacher committed suicide a few weeks ago." This statement is a red flag. A recent loss, particularly by suicide, can significantly impact an adolescent's emotional well-being. Adolescents who are emotionally attached to individuals who die by suicide are at increased risk for suicidal ideation, especially if the loss triggers emotional distress or serves as a model for the adolescent. This concern should prompt further assessment for suicidal thoughts or behaviors.

B. "He is very religious and attends services twice a week." Being religious and attending services regularly is generally a protective factor against suicide. Religious involvement may provide a sense of community, purpose, and support, which can act as a buffer against suicidal ideation.

C. "He spends much of his time with his two school friends." Having a small but close social group is typical for many adolescents and, by itself, is not a risk factor for suicide. It’s important to consider the quality of these relationships, but this statement alone does not suggest immediate concern.

D. "He has slept 9 hours each night for the past 2 years." Sleeping 9 hours a night is generally within the recommended range for adolescents. This does not indicate a risk for suicide and may even suggest that the adolescent is maintaining a healthy sleep schedule.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who is taking risperidone. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

A school nurse is speaking to the mother of a 16 year old male adolescent. The mother has concerns about her son. Which of the following statements by the mother should indicate to the nurse that the adolescent is at risk for suicide?

Correct Answer is A

Explanation

A nurse is making a home visit for a 16-year old adolescent who attempted suicide. Which of the following behaviors should alert the nurse that the adolescent still has suicidal intent?

A nurse is assessing a client who has a new diagnosis of anorexia nervosa. Which of the following findings should the nurse expect?

A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The client is doing calisthenics in the client dining room during lunchtime instead of eating. Which of the following statements should the nurse make?

A nurse is planning to administer olanzapine 10 mg IM to a client who has schizophrenia. Which of the following actions should the nurse take?

A nurse is talking with a client who has schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things." Which of the following responses by the nurse is appropriate?

A nurse is caring for a client who reports an upset stomach after taking chlorpromazine. Which of the following responses should the nurse make?

A nurse is assessing a client who is receiving treatment with multiple antipsychotic medications and who suddenly became ill. Findings include blood pressure changes, hyperpyrexia, and diaphoresis. The nurse should recognize that which of the following adverse effects may be occurring?

A nurse is caring for a client who has generalized anxiety disorder and is taking buspirone. Which of the following adverse effects should the nurse report to the provider?