A nurse is caring for a client who has early-stage Alzheimer's disease. In which of the following actions is the nurse acting as a client advocate?
Requesting a referral for the client to attend reminiscence therapy sessions
Performing an updated cognitive assessment on the client
Providing assistance for the client when ambulating down the hall
Reorienting the client several times throughout the day
The Correct Answer is A
Choice A reason: Reminiscence therapy is a type of intervention that helps clients with Alzheimer's disease recall and share their past experiences, memories, and emotions. This can enhance their self-esteem, mood, and quality of life. By requesting a referral for this therapy, the nurse is advocating for the client's psychosocial needs and preferences.
Choice B reason: Performing an updated cognitive assessment on the client is not an example of advocacy, but rather a standard nursing practice. Cognitive assessments are used to monitor the client's cognitive status and progression of the disease. They do not necessarily reflect the client's wishes or interests.
Choice C reason: Providing assistance for the client when ambulating down the hall is not an example of advocacy, but rather a safety measure. The nurse is helping the client prevent falls and injuries, which are common risks for clients with Alzheimer's disease. This does not imply that the nurse is speaking up for the client or protecting their rights.
Choice D reason: Reorienting the client several times throughout the day is not an example of advocacy, but rather a therapeutic communication technique. The nurse is helping the client cope with confusion and disorientation, which are common symptoms of Alzheimer's disease. This does not indicate that the nurse is supporting the client's goals or values.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Placing a surgical mask on the client during transfer to the unit is not an appropriate action for the nurse to take. Cutaneous anthrax is not transmitted through respiratory droplets, but through direct contact with the spores that enter the skin. A surgical mask does not protect the client or others from the infection.
Choice B reason: Preparing to administer antibiotics to the client is an appropriate action for the nurse to take. Cutaneous anthrax is caused by a bacterium called Bacillus anthracis, which can be treated with antibiotics, such as ciprofloxacin or doxycycline. Antibiotics can prevent the infection from spreading to other parts of the body and causing serious complications.
Choice C reason: Planning to administer an antiviral medication to the client is not an appropriate action for the nurse to take. Cutaneous anthrax is not caused by a virus, but by a bacterium. Antiviral medications are ineffective against bacterial infections and may cause adverse effects or interactions.
Choice D reason: Wearing an N95 respirator mask while caring for the client is not an appropriate action for the nurse to take. An N95 respirator mask is used to protect the nurse from airborne pathogens, such as tuberculosis or measles. Cutaneous anthrax is not airborne, but contact-based. The nurse should wear standard precautions, such as gloves and gown, and wash their hands thoroughly after caring for the client.
Correct Answer is A
Explanation
Choice A reason: The risk of suicide is the highest priority for the charge nurse to assess. The client has several risk factors for suicide, such as major depressive disorder, medication noncompliance, hopelessness, social isolation, and psychomotor retardation. The charge nurse should evaluate the client's suicidal ideation, intent, and plan, and implement safety measures as needed.
Choice B reason: The risk of dehydration is a lower priority than the risk of suicide. The client may be dehydrated due to decreased fluid intake, but this is not a life-threatening condition. The charge nurse should monitor the client's hydration status and encourage oral fluids as appropriate.
Choice C reason: The risk of infection is a lower priority than the risk of suicide. The client does not have any signs or symptoms of infection, such as fever, chills, or leukocytosis. The charge nurse should assess the client's vital signs and laboratory results as indicated, but this is not an urgent issue.
Choice D reason: The risk of seizure is a lower priority than the risk of suicide. The client does not have any history or risk factors for seizure, such as epilepsy, head trauma, or drug withdrawal. The charge nurse should observe the client for any abnormal movements or behaviors, but this is not a likely complication.
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