The nurse is assessing an older adult client who is having difficulty remembering events from earlier in the day and concentrating on the questions being asked. A family member shares that the client's home was recently sold and the client has just moved in with them. Which nursing response best promotes effective communication with the family?
Delirium is often a sign of underlying mental illness, and institutionalization is often necessary.
If the dementia is a result of Alzheimer's disease, it is often reversible even in the late stages.
The client's delirium may be due to depression and is possibly reversible.
The client is exhibiting symptoms of dementia, and because of age, it may be permanent.
The Correct Answer is C
Choice A reason: Suggesting that delirium is often a sign of underlying mental illness and that institutionalization is necessary can be distressing and may not be accurate without further assessment.
Choice B reason: Stating that dementia due to Alzheimer's disease is often reversible even in the late stages is incorrect; Alzheimer's disease is a progressive condition with no current cure.
Choice C reason: Recognizing the possibility of delirium due to depression, which can be reversible, is a hopeful and constructive approach that encourages further evaluation and treatment options.
Choice D reason: Suggesting that symptoms of dementia are permanent because of age can be disheartening and does not consider the potential for reversible causes of cognitive impairment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Sudden swelling, redness, warmth, and pain are more indicative of acute conditions like deep vein thrombosis rather than chronic arterial symptoms.
Choice B reason: Weeping ulcers on lower legs are more commonly associated with venous insufficiency rather than arterial disease.
Choice C reason: Ankle edema and varicose veins are typically associated with venous disorders, not arterial disease.
Choice D reason: Intermittent claudication, which is pain during walking that subsides with rest, is a hallmark of peripheral arterial disease and is an expected finding in clients with this condition.
Correct Answer is D
Explanation
Choice A reason: While obtaining a 12-lead electrocardiogram is important for monitoring cardiac function, it is not as frequent or specific as potassium monitoring for hyperkalemia management.
Choice B reason: Evaluating glucose levels is necessary due to the risk of hypoglycemia from insulin administration, but the priority is monitoring potassium levels in hyperkalemia.
Choice C reason: Monitoring intake and output is part of fluid balance management but is secondary to the critical need to monitor serum potassium levels.
Choice D reason: Frequent assessment of serum potassium levels is essential to evaluate the effectiveness of the dextrose and insulin therapy in lowering potassium levels.
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