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 D
Explanation
Choice A reason: A multigravida client with preeclampsia receiving misoprostol for induction of labor requires specialized obstetrical care due to the complexity of preeclampsia management, which includes monitoring blood pressure, administering antihypertensive agents, and managing potential complications. Misoprostol is used for cervical ripening and labor induction, which involves close monitoring for uterine activity and fetal well-being.
Choice B reason: A client with gestational diabetes undergoing biweekly nonstress tests would benefit from a nurse with obstetrical expertise. Gestational diabetes management includes monitoring blood glucose levels, dietary modifications, and possibly medication administration. Nonstress tests are performed to assess fetal well-being and require interpretation of fetal heart rate patterns in response to fetal movements.
Choice C reason: A client at 32 weeks of gestation with premature rupture of membranes (PROM) needs specialized obstetrical care. Management of PROM may involve expectant management or immediate delivery based on gestational age and fetal and maternal conditions. The risk of infection and complications necessitates obstetrical expertise.
Choice D reason: A primigravida client who is 1 day postoperative following a Cesarean section with a PCA pump is the most suitable assignment for an RN from a medical-surgical unit. Postoperative care involves monitoring vital signs, incision site, and managing pain with the PCA pump, which is within the scope of medical-surgical nursing practice.
Correct Answer is D
Explanation
Choice A reason: Inflammation noted on the tissue edges of a client's wound is a finding that indicates wound infection, not wound healing. The nurse should monitor the wound for signs of infection, such as increased pain, swelling, warmth, odor, or purulent drainage.
Choice B reason: Increase in serosanguineous exudate from a client's wound is a finding that indicates wound deterioration, not wound healing. The nurse should assess the wound for signs of increased tissue damage, such as bleeding, necrosis, or sloughing.
Choice C reason: Erythema on the skin surrounding a client's wound is a finding that indicates wound irritation, not wound healing. The nurse should evaluate the wound for signs of inflammation, such as redness, heat, or tenderness.
Choice D reason: Deep red color on the center of a client's wound is a finding that indicates wound healing, as it shows the presence of granulation tissue. Granulation tissue is a sign of new tissue growth and blood vessel formation, which are essential for wound healing.
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