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 C

Explanation

Choice A rationale

Health information should not be disclosed to an employer for pre-employment screening without the client's consent, as it violates privacy regulations and the client's right to confidentiality. Such disclosures could lead to discrimination or bias in employment decisions.

Choice B rationale

Disclosing health information to a family member without the client's consent is a breach of confidentiality. The client must provide explicit permission, unless the situation involves an immediate risk to the client's or others' safety, which is not indicated here.

Choice C rationale

Sharing health information with a medical interpreter service on behalf of a client is permissible, as it facilitates communication between the client and healthcare providers. This action supports the client's care and ensures accurate understanding of medical information, making it an exception to the confidentiality rule.

Choice D rationale

Disclosing health information to an insurance agency regarding a life insurance policy requires the client's consent. It involves sharing sensitive information that could affect policy terms and premiums. Without consent, this disclosure would breach confidentiality laws.

A. Apply cornstarch powder to the perineal area. B. Turn the client every 4 hours. C. Cleanse the perineal area with povidone-iodine solution. D. Place a moisture barrier ointment over the perineal area.

Correct Answer is D

Explanation

Choice A rationale

Applying cornstarch powder to the perineal area can lead to clumping and skin irritation, especially in a moist environment. It is not recommended for managing fecal incontinence.

Choice B rationale

Turning the client every 4 hours is important for preventing pressure ulcers but does not directly address fecal incontinence. Frequent turning should be combined with other measures for skin protection.

Choice C rationale

Cleansing the perineal area with povidone-iodine solution can be harsh and drying to the skin. It is not typically recommended for routine care of fecal incontinence.

Choice D rationale

Placing a moisture barrier ointment over the perineal area protects the skin from irritation and breakdown caused by fecal matter. It creates a protective layer, which is essential in managing fecal incontinence.

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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

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a group of newly licensed nurses regarding client confidentiality.In which of the following situations can the nurse disclose health information without the client's written consent?

Correct Answer is C

Explanation

A nurse is caring for an older adult client who has fecal incontinence.Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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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?