A nurse is caring for a client who has late-stage Alzheimer's disease and is hospitalized for treatment of the flu. During the night shift, the client is found climbing into the bed of another client who becomes upset and scared. Which of the following actions should the nurse take?

Assist the client to the correct room.

Medicate the patient with antipsychotics.

Move the client to a room at the end of the hall.

Place the client in restraints.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The nurse should prioritize the safety and well-being of both clients involved. Assisting the client with late-stage Alzheimer's disease to the correct room is important to prevent any further confusion or distress. Alzheimer's disease often causes cognitive impairment, memory loss, and disorientation, which can lead to situations where the individual may not recognize their surroundings or the people around them. Guiding the client back to their own room will help reduce confusion, agitation, and potential conflicts with other clients.

Choice B rationale:

Medicating the patient with antipsychotics is not the most appropriate initial action in this situation. Antipsychotic medications are often used to manage severe behavioral disturbances associated with conditions like schizophrenia or dementia, but their use should be carefully considered due to potential side effects. In this scenario, addressing the immediate situation and guiding the client back to their room is more appropriate than resorting to medication.

Choice C rationale:

Moving the client to a room at the end of the hall is not the best choice because it doesn't directly address the current situation. While changing the client's room might be considered in some cases to reduce agitation or wandering, it's not the immediate action needed when the client is found in another client's bed. Guiding the client to the correct room is the priority.

Choice D rationale:

Placing the client in restraints is not an appropriate choice in this situation. Restraints should only be used as a last resort for ensuring the safety of the client or others when less restrictive interventions have failed. Placing a client with Alzheimer's disease in restraints can be traumatic and lead to increased agitation and psychological distress.

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Correct Answer is B

Explanation

Choice A rationale:

Other than possible coordination problems, the client's psychomotor skills are not affected. Severe Intellectual Disability (ID) is characterized by significant limitations in intellectual functioning as well as adaptive behaviors. Coordination problems are not a primary characteristic of severe ID. The main focus is on cognitive and adaptive deficits.

Choice B rationale:

The client communicates wants and needs by "acting out behaviors." Severe ID can lead to challenges in effective communication. "Acting out behaviors" such as tantrums, aggression, or other disruptive actions might be the client's way of expressing themselves when they are unable to communicate verbally or effectively due to their cognitive limitations.

Choice C rationale:

The client can perform some self-care activities independently. Severe ID typically involves significant impairments in adaptive functioning, which includes self-care activities. The ability to perform some self-care activities independently is not consistent with the characteristics of severe ID.

Choice D rationale:

The client has advanced speech development. Severe ID is associated with delayed or impaired speech and language development. Advanced speech development would be contradictory to the diagnosis of severe ID, as this condition is characterized by substantial limitations in communication skills.

A. "If the potential abuser commits to stopping the abuse, healthcare workers are not required to report it." B. "Evidence must exist before reporting." C. "I don't want to defame someone if the report is false." D. "If suspicion of abuse exists, then reporting is mandatory.”

Correct Answer is D

Explanation

The correct answer is choice D: "If suspicion of abuse exists, then reporting is mandatory."

Choice A rationale:

If the potential abuser commits to stopping the abuse, healthcare workers are not required to report it. Rationale: This statement is incorrect. Healthcare workers are mandated reporters, and their primary responsibility is to protect the safety and well-being of the child. Regardless of whether the potential abuser commits to stopping the abuse, suspicion of abuse requires reporting.

Choice B rationale:

Evidence must exist before reporting. Rationale: This statement is incorrect. While concrete evidence can strengthen a case, it is not a prerequisite for reporting suspected child abuse. Reporting is based on reasonable suspicion, not proof. Healthcare workers should err on the side of caution and report any concerns.

Choice C rationale:

I don't want to defame someone if the report is false. Rationale: This statement is incorrect. Reporting suspected child abuse is not about defaming someone, but rather about ensuring the safety of the child. Reporting is a part of the legal and ethical obligations of healthcare workers to protect vulnerable individuals.

Choice D rationale:

If suspicion of abuse exists, then reporting is mandatory. Rationale: This statement is correct. Healthcare workers are mandated reporters and have a duty to report suspected child abuse to appropriate authorities. Reporting is necessary when there is reasonable suspicion, even if definitive evidence is not yet present.

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A nurse is caring for a client who has late-stage Alzheimer's disease and is hospitalized for treatment of the flu. During the night shift, the client is found climbing into the bed of another client who becomes upset and scared. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client diagnosed with Severe Intellectual Disability. Which of the following characteristics should the nurse recognize to be associated with Severe Intellectual Disability?

Correct Answer is B

Explanation

A nurse is teaching a newly licensed nurse about reporting suspected child abuse. Which of the following statements indicates that the newly licensed nurse has the correct information about child abuse?

Correct Answer is D

Explanation

A nurse is caring for a group of older adult clients. Which of the following manifestations indicates one of the clients is experiencing delirium?

A nurse is assessing a client diagnosed with schizophrenia, which has been treated with fluphenazine (Prolixin) for several years. Which of the following findings should the nurse document as manifestations of tardive dyskinesia (TD)?

A nurse is planning a unit orientation for a newly admitted client diagnosed with severe depression. Which of the following should be the nurse's approach?

A nurse is admitting a client who is about to undergo surgery for benign prostatic hypertrophy. The client states, "I don't know what I will do if they find that I have cancer." Which of the following should be the appropriate response by the nurse?

A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting, and now the client is pacing up and down the hallways of the unit. Which of the following actions should the nurse take?

When providing community healthcare teaching regarding the early warning signs of Alzheimer's disease, which signs should the nurse advise family members to report (Select all that apply)?

A nurse is caring for a school-age child who has a history of conduct disorder. Which of the following actions should the nurse take while caring for the child? (Select all that apply.).