A nurse observes a client's spouse sitting alone in the waiting room crying. When approached, the spouse says, "I am really concerned about my husband." Which of the following is an appropriate response by the nurse?
"Tell me what is concerning you.”
"Crying helps us let things out and we feel better.”
"Your husband is making really good progress.”
"Did your husband say something to upset you?”
The Correct Answer is A
Choice A rationale:
The correct choice. In this situation, the nurse's priority is to gather information and provide emotional support. By asking the spouse to share their concerns, the nurse opens up a channel of communication and shows empathy, creating an opportunity to address the spouse's worries and provide reassurance.
Choice B rationale:
While the sentiment that crying can be cathartic and relieving is true, this response does not directly address the spouse's concern or encourage them to share their feelings. It's important to focus on the spouse's feelings rather than just explaining the benefits of crying.
Choice C rationale:
Assuming that the husband is making progress without knowing the specifics of the situation can come across as dismissive of the spouse's concerns. It's important to validate the spouse's emotions and provide support, rather than making assumptions about the husband's progress.
Choice D rationale:
Asking whether the husband said something to upset the spouse might be relevant, but it does not address the spouse's expressed concern about their husband. This response may not foster open communication and emotional support as effectively as choice A.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
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.
Correct Answer is A
Explanation
The correct answer is choice A: "You may experience dizziness upon standing while taking this medication."
Choice A rationale:
This choice is the correct answer because haloperidol, an antipsychotic medication, can cause orthostatic hypotension, which leads to dizziness upon standing. Antipsychotic medications often affect blood pressure regulation and can result in a sudden drop in blood pressure when transitioning from sitting or lying down to standing. This explanation provides essential information to the client to help them understand potential side effects and take necessary precautions.
Choice B rationale:
This choice is incorrect. Haloperidol is not indicated for treating symptoms of obsessive-compulsive disorder (OCD). It is primarily used to manage symptoms of schizophrenia and other psychotic disorders. Providing false information about its indications is not appropriate and may lead to confusion.
Choice C rationale:
This choice is incorrect. Clients should never stop taking antipsychotic medications abruptly without consulting their healthcare provider. Discontinuing such medications can lead to withdrawal effects and a worsening of symptoms. Encouraging the client to stop the medication if side effects are bothersome is not appropriate and could potentially jeopardize their well-being.
Choice D rationale:
This choice is partially correct but not the best answer. While haloperidol can cause excessive salivation (sialorrhea) as a side effect, the primary concern in this situation should be related to orthostatic hypotension and dizziness upon standing. Mentioning excessive salivation would be helpful, but it's secondary to the risk of falls associated with orthostatic hypotension.
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