Nokea
A client with Alzheimer's disease is eating in the dining hall along with the other clients. Thirty minutes later, he says to the nurse, 'When can I have my breakfast? They haven't given me anything to eat yet.' The most appropriate response for the nurse would be:
- A. I saw you eating breakfast 30 minutes ago.'
- B. Are you still not full? I'll ask the kitchen what they served you.'
- C. I can get you some bread if you like. What else would you like?'
- D. You have to wait until it's lunchtime.'
Correct Answer: C
Rationale: Offering food compassionately addresses the client's memory impairment without causing distress.
You may also like to solve these questions
A 24-year old woman presents to the emergency department and appears as shown in the exhibit. What type of injury does this assessment finding suggest?
- A. CSF leak
- B. Basilar skull fracture
- C. Brown-Sequard syndrome
- D. Subarachnoid hemorrhage
Correct Answer: B
Rationale: Without the exhibit, basilar skull fracture is assumed due to context (e.g., raccoon eyes or CSF leak signs).
The nurse is developing a plan of care for a client with advanced Alzheimer's disease. Which of the following should the nurse include?
- A. Assess the client's risk for falls
- B. Monitor the client for hyperorality
- C. Provide consistent caregivers
- D. Obtain a prescription for as-needed (PRN) diphenhydramine
- E. Foster a low-stimulation environment
- F. Offer limited choices
Correct Answer: A,B,C,E,F
Rationale: These interventions address safety, behavior, and comfort in advanced Alzheimer's disease.
This nurse is caring for a client who is receiving prescribed carbamazepine. Which of the following findings would indicate a therapeutic response?
- A. Decreased mood lability
- B. Steady gait
- C. Urinary continence
- D. Increased bone mass
Correct Answer: B
Rationale: Carbamazepine is an anticonvulsant used for seizures, and a steady gait indicates reduced seizure activity or improved neurological stability. Mood lability, urinary continence, and bone mass are not primary therapeutic outcomes.
The nurse is caring for a client with a migraine headache. Which assessment findings should the nurse expect?
- A. Unilateral frontotemporal pain
- B. Nausea
- C. Photophobia
- D. Fever
- E. Nuchal rigidity
- F. Vomiting
Correct Answer: A,B,C,F
Rationale: Migraine headaches typically present with unilateral pain, nausea, photophobia, and vomiting.
The nurse is caring for a client with a basilar skull fracture. Which assessment finding requires immediate follow-up?
- A. Periorbital ecchymosis
- B. Retroauricular or mastoid ecchymosis
- C. Temperature 100.9°F (38.3°C)
- D. Headache
Correct Answer: A,B
Rationale: Periorbital and retroauricular ecchymosis (raccoon eyes and Battle's sign) are hallmark signs of basilar skull fracture, requiring immediate follow-up.