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 ["B","D","E"]
Explanation
Choice A reason: Sloughing tissue around wound edges may require debridement but does not typically require immediate intervention unless there is a significant change in the wound's condition.
Choice B reason: Loss of sensation could indicate nerve damage or developing compartment syndrome, which is a medical emergency requiring immediate intervention to prevent permanent damage.
Choice C reason: Weeping serosanguineous fluid is expected in burn wounds and does not necessarily require immediate intervention unless there is a significant increase in output or other signs of infection.
Choice D reason: Increased pain and pressure are signs of potential compartment syndrome or infection, both of which require prompt assessment and possible intervention.
Choice E reason: A change in the quality of peripheral pulses may indicate vascular compromise, which requires immediate intervention to restore circulation and prevent tissue death.

Correct Answer is B
Explanation
Choice A reason: Discussing symptomless partners may give false reassurance, as herpes can be transmitted even when symptoms are not present.
Choice B reason: Notifying sexual partners is crucial for public health and the prevention of further transmission of STIs.
Choice C reason: While it's true that STIs are reported, this does not provide the client with actionable advice for their situation.
Choice D reason: Most contraceptives do not protect against STIs like genital herpes, which is spread by skin-to-skin contact.
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