Nokea
A 90 y.o. nursing home resident with stage 2 Alzheimer's disease is found alone and crying in the dining room. She says she lost her mother and doesn't know what to do. Which response by the nurse will help calm the resident?
- A. "Remember your mother has been dead for 30 years. You forgot again, didn't you?"
- B. "I'm sorry you lost your mother; let's go and try to find her."
- C. "Are you feeling frightened? I'm here and I will help you."
- D. "You are 90 years old. It is impossible for your mother to still be living. I know if you try, you can figure out what to do."
Correct Answer: C
Rationale: Option C, "Are you feeling frightened? I'm here and I will help you," is the most appropriate response to help calm the resident. The resident is experiencing confusion and distress, likely due to her Alzheimer's disease. Invalidating her feelings by reminding her of the reality may lead to more confusion and distress. Instead, acknowledging the resident's emotions, offering support, and reassuring her of your presence can help calm her down and provide comfort in the moment. It is important to provide emotional support and reassurance to individuals with Alzheimer's disease, rather than focusing on correcting their statements or reminding them of reality.
You may also like to solve these questions
The parents of a newborn with a strawberry hemangioma ask the nurse what the treatment will be. What information does the nurse need to include in the response?
- A. Excision of the lesion will be necessary.
- B. Injections of prednisone into the lesion will reduce it.
- C. No treatment is usually necessary because of the high rate of spontaneous involution.
- D. Pulsed dye laser treatments will be necessary immediately to prevent permanent disability.
Correct Answer: C
Rationale: The correct information the nurse should provide to the parents is that no treatment is usually necessary for a strawberry hemangioma because of the high rate of spontaneous involution. Strawberry hemangiomas are common vascular tumors in infants that typically appear in the first few weeks of life. They usually grow rapidly for the first several months and then begin to shrink and eventually disappear on their own. In most cases, the hemangioma resolves without the need for any intervention. Therefore, reassuring the parents that observation is the primary management approach is important, unless complications such as ulceration, bleeding, or obstruction occur.
Which is the leading cause of death after heart transplantation?
- A. Infection
- B. Rejection
- C. Cardiomyopathy
- D. Heart failure
Correct Answer: A
Rationale: Infection is the leading cause of death after heart transplantation. Following transplantation, patients are at a higher risk of infections due to the immunosuppressive medications they must take to prevent organ rejection. These medications suppress the immune system's responses, leaving the patient susceptible to various infections such as bacterial, viral, and fungal infections. Without timely diagnosis and treatment, these infections can lead to serious complications and even death in heart transplant recipients. Therefore, the careful monitoring and management of infections are crucial in post-transplant care to improve outcomes and prevent mortality.
The basic principle of healthy sleep hygiene which is NOT included is
- A. set routine
- B. avoid stimulating activities as playing computer games
- C. makes sure child spends time outside every day
- D. gives a heavy meal within an hour of bedtime
Correct Answer: D
Rationale: Heavy meals close to bedtime disrupt sleep.
Which is the most common cause of anemia in preterm newborns?
- A. Frequent blood sampling
- B. Respiratory distress syndrome
- C. Meconium aspiration syndrome
- D. Persistent pulmonary hypertension
Correct Answer: A
Rationale: The most common cause of anemia in preterm newborns is frequent blood sampling. Preterm infants are often subject to numerous blood tests for various reasons such as monitoring oxygen and blood gas levels, assessing bilirubin levels, infection screening, and more. These repeated blood withdrawals lead to a loss of red blood cells and can contribute to the development of anemia in preterm infants. Anemia in preterm newborns can have significant consequences, including impaired growth and development, delayed hospital discharge, and the potential need for blood transfusions. Therefore, minimizing unnecessary blood sampling and utilizing non-invasive monitoring methods whenever possible are key strategies in preventing and managing anemia in preterm newborns.
Two hours after arriving on the medical-surgical unit, the client develops dyspnea. SaO2 is 91%, and the client is exhibiting audible wheezing and use of accessory muscles. Which of the following medications should the nurse expect to administer?
- A. Antibiotic
- B. Beta-blocker
- C. Antiviral
- D. Beta2 agonist D.The nurse should expect to administer a beta2 agonist. Beta2 agonists are used for relief of acute symptoms. Neither an antibiotic, an antiviral, nor a beta blocker are indicated for this condition. of the following to guide interpretation of severity of findings?
Correct Answer: D
Rationale: In this situation, the client is experiencing dyspnea, audible wheezing, and decreased oxygen saturation, indicating the presence of respiratory distress, likely due to bronchoconstriction. These are classic symptoms of an acute asthma exacerbation or an obstructive respiratory condition. Beta2 agonists, such as albuterol, are bronchodilators that work by relaxing the muscles in the airways, relieving bronchoconstriction and improving airflow. Administering a beta2 agonist promptly is crucial to provide relief and improve the client's respiratory status. Antibiotics, antivirals, and beta-blockers are not appropriate treatments for acute bronchoconstriction or asthma exacerbation.