As the discharge date for a client to leave gets closer, the client states, “I’m afraid to leave here. I’m afraid for my well-being and safety.” Which nursing statement is most supportive?
“This is a difficult transition. Let’s formulate a plan to keep you feeling safe.”
“It’s the policy that patients can only live here for 30 days. Let’s try to extend it.”
“You’ve had a month to come up with a plan to work on your well-being.”
“Hopefully you learned from being in counseling. I’m sure this will work out fine.”
The Correct Answer is A
Choice A Reason:
“This is a difficult transition. Let’s formulate a plan to keep you feeling safe.”
This response is the most supportive because it acknowledges the client’s feelings and offers a proactive solution. By recognizing the difficulty of the transition and suggesting a plan to ensure the client’s safety, the nurse provides reassurance and practical support. This approach helps to build trust and shows empathy, which is crucial in a therapeutic relationship.
Choice B Reason:
“It’s the policy that patients can only live here for 30 days. Let’s try to extend it.”
While this response acknowledges the client’s fear, it focuses on policy rather than addressing the client’s immediate emotional needs. Extending the stay might not be feasible or beneficial in the long term. The primary goal should be to empower the client to feel safe and supported outside the facility.
Choice C Reason:
“You’ve had a month to come up with a plan to work on your well-being.”
This response can come across as dismissive and unsupportive. It implies that the client should have already resolved their fears, which may increase their anxiety and feelings of inadequacy. The focus should be on providing immediate support and reassurance rather than criticizing the client’s progress.
Choice D Reason:
“Hopefully you learned from being in counseling. I’m sure this will work out fine.”
This response is overly optimistic and does not address the client’s current fears. It provides false reassurance without offering any concrete support or solutions. The client needs to feel heard and supported, not just reassured that everything will be fine.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E"]
Explanation
The correct answer is c, e.
Choice A Reason:
The statement “Clear and organized speech” is incorrect. Clients with delirium often exhibit disorganized thinking and speech. Their speech may be rambling, irrelevant, or incoherent, reflecting their fluctuating mental state. Clear and organized speech is more characteristic of a person without cognitive impairment or with stable cognitive function.
Choice B Reason:
The statement “Increased attention and focus” is incorrect. Delirium is characterized by a disturbance in attention and awareness. Clients with delirium typically have difficulty sustaining or shifting attention, which is a key diagnostic criterion. Increased attention and focus are not consistent with the presentation of delirium.
Choice C Reason:
The statement “Fluctuating levels of consciousness” is correct. One of the hallmark features of delirium is the fluctuation in the level of consciousness throughout the day3. Clients may experience periods of lucidity interspersed with confusion and disorientation. This fluctuation is a critical diagnostic indicator of delirium.
Choice D Reason:
The statement “Stable and consistent cognitive function” is incorrect. Delirium is marked by an acute change in cognitive function, which is neither stable nor consistent. Cognitive functions such as memory, orientation, and language are typically impaired and fluctuate over time. Stable cognitive function would not support a diagnosis of delirium.
Choice E Reason:
The statement “Agitation and aggression” is correct. Clients with delirium often exhibit behavioral disturbances, including agitation and aggression. These symptoms can result from the confusion and disorientation experienced during delirium. Recognizing these behavioral changes is important for the diagnosis and management of delirium.
Correct Answer is A
Explanation
Choice A Reason:
Prevents the breakdown of acetylcholine.
Galantamine is an acetylcholinesterase inhibitor, which means it works by preventing the breakdown of acetylcholine in the brain. Acetylcholine is a neurotransmitter that is important for memory and learning. By inhibiting the enzyme that breaks down acetylcholine, galantamine increases the levels of acetylcholine available in the brain, which can help improve cognitive function in patients with Alzheimer’s disease1. This mechanism of action is crucial because it directly addresses the cholinergic deficit observed in Alzheimer’s disease.
Choice B Reason:
Decreases amyloid plaques in the brain.
This statement is incorrect. Galantamine does not work by decreasing amyloid plaques in the brain. Amyloid plaques are one of the pathological hallmarks of Alzheimer’s disease, but galantamine’s primary mechanism of action is related to acetylcholine metabolism. Other treatments and research efforts focus on targeting amyloid plaques, but this is not the function of galantamine.
Choice C Reason:
Increases acetylcholine levels in the brain.
While this statement is partially correct, it is not as precise as the correct answer. Galantamine increases acetylcholine levels indirectly by preventing its breakdown rather than directly increasing its production. The distinction is important because the therapeutic approach involves inhibiting the enzyme acetylcholinesterase, which breaks down acetylcholine, thereby increasing its availability.
Choice D Reason:
Limits neurotransmitter engagement of NMDA receptors.
This statement is incorrect. Limiting neurotransmitter engagement of NMDA receptors is the mechanism of action for a different class of Alzheimer’s medications, such as memantine. Galantamine does not affect NMDA receptors; instead, it enhances cholinergic function by inhibiting acetylcholinesterase and potentiating nicotinic receptors.
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