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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is ["A","B","C","E"]
Explanation
Choice A rationale:
Tachycardia (rapid heart rate) is a potential physical symptom of alcohol withdrawal. When alcohol-dependent individuals suddenly stop or reduce their alcohol intake, it can lead to increased sympathetic nervous system activity, resulting in elevated heart rate.
Choice B rationale:
Tremors (shakes) are common during alcohol withdrawal due to the suppression of the central nervous system by alcohol. Abrupt cessation of alcohol can lead to overactivity in the nervous system, resulting in tremors.
Choice C rationale:
Hallucinations can occur during alcohol withdrawal and are usually visual or tactile in nature. These hallucinations are often referred to as alcoholic hallucinosis and can be distressing for the individual experiencing them.
Choice E rationale:
Seizures can be a severe consequence of alcohol withdrawal. Known as alcohol withdrawal seizures, these episodes can occur within the first 48 hours after cessation of heavy alcohol consumption and are attributed to the hyperexcitability of the central nervous system.
Choice D rationale:
Hypotension (low blood pressure) is not typically associated with alcohol withdrawal. In fact, alcohol withdrawal often leads to an increase in blood pressure and heart rate due to the hyperactivity of the sympathetic nervous system.
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