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 B

Explanation

Choice A reason: While it's important to know if the client can lie prone, this is not the most critical piece of information prior to an intravenous pyelogram.

Choice B reason: Asking about a shellfish allergy is crucial because the contrast dye used in an intravenous pyelogram may contain iodine, which can cause an allergic reaction in individuals with shellfish allergies.

Choice C reason: Knowing the last time the client had a bowel movement is less critical than knowing about potential allergies to the contrast dye.

Choice D reason: While it's important to know about medication schedules, the risk of an allergic reaction to the contrast dye is a more immediate concern that could affect the safety of the procedure.

A. Evaluate the effectiveness of this measure to stimulate client voiding. B. Recommend a complete bath to cleanse the perineal area more fully. C. Suggest contacting the healthcare provider for a prescription for catheter insertion. D. Instruct the PN that this technique promotes infection in elderly females.

Correct Answer is A

Explanation

Choice A reason: Pouring warm water over the perineal area can stimulate the micturition reflex, which may help the client void. It is a non-invasive, first-line intervention to promote natural voiding in clients with urinary incontinence. The nurse should evaluate its effectiveness as it can be a simple yet effective method to assist the client.

Choice B reason: While recommending a complete bath may help maintain hygiene, it does not directly address the immediate need to stimulate voiding. The nurse's priority is to manage the incontinence issue effectively and a bath can be considered after addressing the client's immediate needs.

Choice C reason: Suggesting catheter insertion may be premature without first attempting less invasive measures. Catheterization carries risks such as infection and should be considered only when other interventions are ineffective or not feasible.

Choice D reason: There is no evidence to suggest that pouring warm water over the perineal area promotes infection in elderly females. In fact, proper perineal care is essential in preventing infections, especially in clients with incontinence.

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Naxlex Comprehensive Predictor Exams

A client is scheduled for an intravenous pyelogram today. The nurse instructs the client that the x-ray visualizes the kidneys, ureters, and bladder. Which information is most important for the nurse to gather before the client goes for the x-ray?

Correct Answer is B

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?

Correct Answer is A

Explanation

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?

The school nurse is preparing a presentation for elementary school teachers to inform them about when a child should be referred to the school clinic for further follow-up. The teachers should be instructed to report which situation(s) to the school nurse? Select all that apply.

While the nurse is preparing a scheduled IV medication, the client states that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement?

A 22-year-old client is admitted to the hospital in diabetic ketoacidosis (DKA). The client's parent is insisting on knowing the laboratory test results. Which is the best response for the nurse to provide?

The nurse places an opioid patch on the chest of a client with intractable pain who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client?

A client is admitted with the diagnosis of Wernicke's syndrome. Which assessment finding should the nurse use in planning the client's care?

A nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

The nurse implements a primary prevention program for sexually transmitted diseases in a nurse-managed health center. Which outcome indicates that the program was effective?