The spouse of a 67-yr-old male patient with early stage Alzheimer's disease (AD) tells the nurse, "I am exhausted from worrying all the time. I don't know what to do." Which actions are best for the nurse to take at this time? Select All that Apply
Ask the spouse what she knows about dementia care options.
Suggest placement into a long-term care facility.
Teach the spouse about adult day care as a possible respite.
Suggest that the spouse consult with the physician for antianxiety drugs.
Offer ideas for ways to distract or redirect the patient.
Correct Answer : A,C
Choice A Rationale: Asking the spouse what she knows about dementia care options is a good starting point to assess her knowledge and provide information and resources, and empowering her to make informed decisions.
Choice B Rationale: Suggesting placement into a long-term care facility should not be the first option but can be explored if necessary, based on the client's condition and the caregiver's needs.
Choice C Rationale: Teaching the spouse about adult day care as a possible respite is a way of offering support and relief for the caregiver, who may experience stress and burnout from the constant demands of caring for a patient with AD.
Choice D Rationale: Suggesting that the spouse consult with the physician for antianxiety drugs is not helpful, as it may imply that the spouse's feelings are abnormal or that she needs medication to cope.
Choice E Rationale: Offering ideas for ways to distract or redirect the patient is not relevant to the spouse's needs, as it does not address her exhaustion and worry.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Rationale: Assessing the client for bladder distention is the first and most crucial step in managing autonomic dysreflexia. Bladder distention is a common trigger for this condition in clients with spinal cord injuries. Identifying and addressing the cause (bladder distention) is the priority to prevent further complications.
Choice B Rationale: Laying the client flat may not resolve the underlying cause of autonomic dysreflexia and should be done after identifying and addressing the trigger.
Choice C Rationale: Obtaining the client's heart rate is important but should come after assessing for bladder distention since the primary concern in autonomic dysreflexia is elevated blood pressure due to a noxious stimulus.
Choice D Rationale: Administering a nitrate antihypertensive may be necessary if other interventions do not resolve the blood pressure elevation, but it should not be the first action. Identifying and addressing the cause, such as bladder distention, is the priority.
Correct Answer is D
Explanation
Choice A Rationale: Guillain-Barre syndrome does not typically cause enlargement of parotid and salivary glands, leading to drooling.
Choice B Rationale: Obstructed blood flow to the brain is not the primary cause of the described symptoms in Guillain-Barre syndrome.
Choice C Rationale: Deficiency of thiamine and pyridoxine in the central nervous system is not a characteristic feature of Guillain-Barre syndrome.
Choice D Rationale: In Guillain-Barre syndrome, demyelination affects cranial nerves responsible for swallowing and the gag reflex, leading to difficulties in swallowing secretions and drooling.
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