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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: Mucous strings in the drainage are normal as mucus is produced by the intestine, which is now part of the urinary diversion.

Choice B reason: A red edematous stomal appearance can be expected postoperatively as part of the normal healing process.

Choice C reason: Stomal output of 40 mL in the last hour is within the normal range for postoperative urinary output.

Choice D reason: Liquid brown drainage from the stoma could indicate a problem such as an infection or bowel content leakage and should be reported immediately.

A. Move the client to a private room, keep the door closed, and initiate droplet precautions. B. Place the nasal swab specimen for COVID-19 directly into a biohazard bag. C. Assist the client to recall everyone possibly exposed since the onset of symptoms. D. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus.

Correct Answer is A

Explanation

Choice A reason: This is the most immediate and important action to take to prevent the potential spread of COVID-19, especially in a healthcare setting where there is a risk of infecting others.

Choice B reason: While placing the swab in a biohazard bag is a standard procedure, it is not as critical as isolating the patient to prevent transmission.

Choice C reason: Assisting the client to recall contacts is important for contact tracing, but it is secondary to immediate infection control measures within the clinic.

Choice D reason: Educating the client on preventive measures is important, but it does not take precedence over immediate actions to prevent the spread of infection in the clinic.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with bladder cancer had surgical placement of a ureter ileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately?

Correct Answer is D

Explanation

Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?

Correct Answer is A

Explanation

A nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take?

An older adult client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?

The nurse is assisting the healthcare provider with a wound debridement at the bedside of a client who is mildly confused. The client is draped and a sterile field is created. Which nursing intervention should the nurse implement for client safety?

On admission to the emergency department, a client who was diagnosed with bipolar disorder 3 years ago reports taking a handful of medications this morning and left a suicide note for the family. Which information is most important for the nurse to obtain?

One hour following cardiac catheterization via the left femoral site, a client reports feeling weak and dizzy. Assessment reveals that the client's dressing is dry and intact. Which action should the nurse take next?

Which nursing responsibility is related to health promotion and teaching for the client with rheumatoid arthritis?

A nurse is caring for a client who reports having run out of aspirin a week ago and has been taking ibuprofen as a substitute. Which information should the nurse obtain from the client first?