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.”
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Placing an identification tag on the outside of the client's shroud is essential for proper identification, especially in cases requiring an autopsy. This practice ensures that the deceased person is accurately identified throughout the process and helps prevent any mix-ups or misidentifications.
Choice B rationale
Asking the assistive personnel to document the client's time of death is incorrect as it is the nurse's responsibility to document the time of death accurately in the medical records, not the assistive personnel's duty.
Choice C rationale
Wearing sterile gloves when cleaning the client's body is not necessary. Standard precautions and the use of non-sterile gloves are sufficient for postmortem care unless there are specific reasons requiring sterility, which is uncommon.
Choice D rationale
Removing the client's dentures and giving them to the client's family is incorrect for an autopsy case. Dentures should be left in place to maintain the integrity of the body and to ensure that all personal effects are accurately documented and managed.
Correct Answer is B
Explanation
Choice A rationale
Standing with the crutch tips against the feet is incorrect. Proper crutch placement involves positioning the crutches slightly forward and to the side of the feet to provide stability and prevent tripping.
Choice B rationale
Bearing weight on the unaffected leg is the correct instruction for using the three-point gait. This technique allows the client to move the crutches and the affected leg together while bearing weight on the unaffected leg, promoting balance and mobility.
Choice C rationale
Keeping the crutches at the level of the axillae is incorrect. Crutches should be positioned with a 1-2 inch gap below the axillae to prevent nerve damage and ensure proper support.
Choice D rationale
Holding the arms straight when walking is incorrect. The elbows should be slightly bent to allow for comfortable movement and better control of the crutches.
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