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:

Bizarre behavior is not a negative symptom of schizophrenia but rather a positive symptom. Positive symptoms involve an excess or distortion of normal functioning and include hallucinations, delusions, and disorganized speech or behavior. Bizarre behavior falls under the category of disorganized behavior, which is a positive symptom.

Choice B rationale:

Waxy flexibility is a characteristic of negative symptoms in schizophrenia. Negative symptoms involve a reduction or loss of normal functioning and include behaviors like social withdrawal, reduced emotional expression, and decreased motivation. Waxy flexibility refers to the phenomenon where a person with schizophrenia can be molded into different positions and maintain those positions for an extended period. This rigidity is a manifestation of reduced spontaneous movement, which is a negative symptom.

Choice C rationale:

Somatic delusions are a type of positive symptom seen in schizophrenia. These delusions involve false beliefs about one's body, health, or bodily functions. They are not negative symptoms, which are characterized by deficits in normal functioning.

Choice D rationale:

Illogicality is related to disorganized thinking, which is a positive symptom of schizophrenia. Individuals experiencing disorganized thinking may have difficulty organizing their thoughts coherently and logically, leading to speech that is difficult to follow. Negative symptoms, on the other hand, involve a decrease in normal functioning and do not pertain to logical coherence.

A. Set limits for the relationship. B. Engage in affectionate interactions with the client. C. Promote the use of transference by the client. D. Instruct the client on how he should behave.

Correct Answer is A

Explanation

The correct answer is choice A: Set limits for the relationship.

Choice A rationale:

Setting limits for the therapeutic relationship (Choice A) is an essential nursing action. Boundaries help create a safe and structured environment, ensuring that both the nurse and client maintain appropriate roles. Limits prevent overstepping boundaries that could compromise the therapeutic alliance.Setting limits for the relationship is an essential part of establishing a therapeutic relationship in a mental health setting. This helps to maintain professional boundaries and ensures that the relationship remains focused on the client’s needs and therapeutic goals.

Choice B rationale:

Engaging in affectionate interactions with the client (Choice B) is not appropriate in a therapeutic relationship. Professionalism and maintaining appropriate boundaries are crucial in psychiatric nursing. Affectionate interactions could blur the lines between the therapeutic relationship and personal relationships, potentially harming the client's progress.

Choice C rationale:

Promoting the use of transference by the client (Choice C) is not a suitable approach. Transference occurs when a client projects feelings and emotions onto the nurse based on past experiences. While it can be valuable to explore transference, actively promoting it could lead to confusion and misunderstandings in the therapeutic relationship.

Choice D rationale:

Instructing the client on how they should behave (Choice D) is contrary to the principles of a therapeutic relationship. The therapeutic relationship is client-centered, where the nurse supports the client's self-discovery and growth. Directing the client's behavior undermines their autonomy and inhibits their progress.

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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 performing an admission assessment on a client who has been diagnosed with schizophrenia. Which of the following findings should the nurse identify as a negative symptom?

Correct Answer is B

Explanation

A nurse in a mental health clinic is attempting to develop a therapeutic relationship with a client. Which of the following should be the appropriate action by the nurse?

Correct Answer is A

Explanation

A nurse is creating a plan of care for a client who is experiencing mania. Which of the following interventions should the nurse include in the plan?

A nurse is caring for a child who has autism spectrum disorder. Which of the following findings should the nurse expect? (Select all that apply.).

The community health nurse recognizes that which of the following mental health issues is most prevalent in the homeless population?

A nurse in a mental health facility is caring for a client who is upset about the loss of privileges due to repetitive negative behavior. Which of the following statements by the nurse demonstrates the effective use of assertive communication?

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 male client is admitted to the unit with a possible diagnosis of delirium. Which statement by the client's wife best supports the diagnosis?

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?