A home health nurse is visiting a client who has advanced Alzheimer's disease.
The client's partner states, "I miss being able to go places with my friends.”. Which of the following is an appropriate response by the nurse?

"We can discuss this when you're not feeling overwhelmed.”.

"Have you tried taking your partner with you when you go out?"

"Tell me more about your expectations.”.

"I understand how you feel. I've had a relative go through the same thing.”

Answer and Explanation

The Correct Answer is C

Choice A rationale

Telling the client's partner to discuss their feelings when not feeling overwhelmed is dismissive. It does not address their current emotional state or offer support. This response can make the partner feel unheard and may not provide immediate relief or understanding.

Choice B rationale

Suggesting that the partner take the client with them when going out may not be practical, especially considering the advanced stage of Alzheimer's disease. This response can show a lack of understanding of the challenges faced by caregivers of individuals with severe cognitive impairment.

Choice C rationale

Asking the partner to share more about their expectations opens a dialogue and shows empathy. It allows the nurse to understand the partner’s feelings and needs better, providing an opportunity for supportive and individualized advice.

Choice D rationale

While expressing understanding and sharing a personal experience might build rapport, it can shift the focus away from the partner's feelings and needs. The nurse should remain client-centered, providing support specific to the partner's situation rather than comparing it to their own.

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Correct Answer is D

Explanation

Choice A rationale

Placing one hand over the other against the upper body of the gown increases the risk of contamination. The sterile field must be maintained by keeping hands in a position where they are less likely to come into contact with non-sterile surfaces.

Choice B rationale

Clasping hands behind the body at the waist can also lead to contamination, as the hands may inadvertently touch the gown, which may not be sterile in that area. It’s essential to keep hands in a position where they are less likely to become contaminated.

Choice C rationale

Keeping arms at the sides with hands in a relaxed position might cause hands to brush against non-sterile surfaces or clothing, leading to contamination. Therefore, this position is not recommended for maintaining sterility.

Choice D rationale

Interlocking fingers and holding hands away from the body above the waist is the proper technique for maintaining sterility. This position ensures that the hands are kept in the sterile field and away from non-sterile surfaces, reducing the risk of contamination.

A. "I'm glad to have the opportunity to choose what kind of care I receive while I still can.”. B. "I can't change my mind about the care I will receive once I sign my living will.”. C. "Once I fill out my living will, there will be a 1-month delay before it is legally binding.”. D. "If I want life support, I'll need to sign a separate consent form first.”.

Correct Answer is A

Explanation

Choice A rationale

This statement indicates that the client understands advance directives allow them to make decisions about their care while they are still capable. This reflects the purpose of advance directives, which is to respect and uphold the client’s autonomy and choices regarding their medical care.

Choice B rationale

This statement is incorrect because clients can change their advance directives or living will at any time. The purpose of these documents is to provide flexibility and ensure that the client's current wishes are followed.

Choice C rationale

This statement is incorrect. Once a living will is signed and witnessed or notarized, it becomes legally binding without a waiting period. The delay mentioned here is not a part of the advance directive process.

Choice D rationale

This statement is not accurate. A living will usually includes decisions about life support, and a separate consent form is not typically needed for those decisions. The client’s wishes regarding life support would be documented in the living will itself.

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A home health nurse is visiting a client who has advanced Alzheimer's disease. The client's partner states, "I miss being able to go places with my friends.”. Which of the following is an appropriate response by the nurse?

Nursing Test Bank

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Correct Answer is A

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A home health nurse is visiting a client who has advanced Alzheimer's disease.
The client's partner states, "I miss being able to go places with my friends.”. Which of the following is an appropriate response by the nurse?