Exhibit. The spouse of a male client with early-stage Alzheimer's disease (AD) tells the nurse, "I am just exhausted from the constant worry. I don't know what to do." Which action is best for the nurse to take next? (Select All That Apply.)

Suggest that a long-term care facility be considered.

Offer ideas for ways to distract or redirect the client.

Ask the spouse what she knows and has considered about dementia care options.

Educate the spouse about the availability of adult care as a respite.

Suggest that the spouse consults with the physician for anti-anxiety drugs.

Answer and Explanation

Correct Answer : B,D

The correct answers are choices B and D: "Offer ideas for ways to distract or redirect the client." and "Educate the spouse about the availability of adult care as a respite."

Choice A rationale:

Suggesting a long-term care facility should not be the first action. Early-stage Alzheimer's clients can often remain at home with proper support, and suggesting institutionalization might not be appropriate at this stage.

Choice B rationale:

This is a correct choice. Engaging the client with Alzheimer's in activities that distract or redirect their focus can be helpful. This approach can alleviate the spouse's concerns and provide some relief from exhaustion.

Choice C rationale:

While discussing dementia care options with the spouse is important, it might not directly address the spouse's current exhaustion and feelings of helplessness.

Choice D rationale:

This is a correct choice. Educating the spouse about adult care options for respite can provide much-needed breaks for the caregiver. Caring for someone with Alzheimer's can be emotionally and physically draining, so respite care can offer temporary relief.

Choice E rationale:

Suggesting anti-anxiety drugs for the spouse is not the best first action. While addressing caregiver stress is important, suggesting medication should come after considering other supportive measures.

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Correct Answer is B

Explanation

Choice A rationale:

Identifying the client's coping skills is an important assessment, but in the context of acute anxiety requiring crisis intervention, immediate safety takes precedence over assessment. Coping skills assessment can follow once the client is stable.

Choice B rationale:

Protecting the client from injury to himself is the highest priority in this scenario. Acute anxiety can lead to behaviors that pose a risk to the client's safety, such as self-harm or suicide. Ensuring the client's physical safety is paramount.

Choice C rationale:

Determining the cause of the client's anxiety is relevant for long-term care but not the immediate priority during crisis intervention. Immediate safety concerns must be addressed first.

Choice D rationale:

Ensuring that the client feels safe is important, but physical safety takes precedence. The client's subjective feeling of safety may not necessarily prevent them from engaging in harmful behaviors.

A. A child who has a BMI indicating obesity. B. A child who uses the call light frequently. C. A child who has frequent visitors. D. A child whose parents answer questions for the child.

Correct Answer is D

Explanation

The correct answer is choice D. A child whose parents answer questions for the child.

Choice A rationale:A child with a BMI indicating obesity is not necessarily a sign of abuse. Obesity can result from various factors, including genetics, diet, and lifestyle. While it is important to address obesity for the child’s health, it does not directly indicate abuse.

Choice B rationale:A child who uses the call light frequently may be seeking attention or reassurance, but this behavior alone does not indicate abuse. Frequent use of the call light can be due to anxiety, fear, or a need for comfort, which can be addressed through appropriate nursing care and support.

Choice C rationale:A child who has frequent visitors is generally seen as having a strong support system. Frequent visits from family and friends usually indicate that the child is well-cared for and loved. This is not typically a sign of abuse.

Choice D rationale:A child whose parents answer questions for the child can be a red flag for abuse. This behavior may indicate that the parents are controlling and do not allow the child to speak for themselves, which can be a sign of emotional or psychological abuse. It is important for healthcare providers to observe interactions between the child and parents and assess for any signs of coercion or control.

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Exhibit. The spouse of a male client with early-stage Alzheimer's disease (AD) tells the nurse, "I am just exhausted from the constant worry. I don't know what to do." Which action is best for the nurse to take next? (Select All That Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who requires crisis intervention for acute anxiety. Which of the following nursing actions is the highest priority?

Correct Answer is B

Explanation

A nurse is providing care to children on a general pediatric unit. Which of the following children should the nurse identify as a potential victim of abuse?

Correct Answer is D

Explanation

A nurse notices that a client who has moderate anxiety is pacing the corridor and rambling. As the nurse approaches, the client states, "I am at the end of my rope. I don't think I can take any more bad news." Which of the following responses should the nurse make?

The nurse is assessing a client in group therapy on which type of techniques for modifying behaviors would be most appropriate. The nurse has decided to use covert sensitization. Which of the following statementbest describes this type of therapy?

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 caring for a client who is withdrawing from opioids. Which of the following medications would the nurse prepare to administer?

A nurse is assessing a client who is sharing information regarding concerns about their marriage. The client states "My spouse and I argue most times." Which of the following statements by the nurse requires intervention by the charge nurse?

A nurse is interviewing a client during admission to an alcohol treatment center. Which of the following approaches should the nurse take?

A nurse in a mental health facility is interacting with a client who is angry and becoming increasingly aggressive. Which of the following actions should the nurse take?

A nurse in the ER is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?