Nokea
A client with dementia was admitted to a dementia unit after she began persistently wandering away from home. The nursing staff should plan to:
- A. Provide unlimited freedom because the client has no place to go in the new neighborhood
- B. Provide one-to-one supervision when the client is ambulatory
- C. Place the client in a geriatric chair with a tray across the lap
- D. Provide the client with an electronic alarm that sounds when the client nears the exit door
Correct Answer: D
Rationale: The correct answer is D because providing the client with an electronic alarm that sounds when she nears the exit door is the best option to ensure her safety. This approach allows for monitoring without restricting her movement excessively. Choice A is incorrect as unlimited freedom poses risks. Choice B is not practical or feasible long-term. Choice C is not person-centered and may lead to discomfort and agitation. The electronic alarm in choice D is the most effective and least intrusive method to prevent wandering while respecting the client's autonomy.
You may also like to solve these questions
In learning disabilities, the name for mathematical disorder is:
- A. Dyspraxia
- B. Dyslexia
- C. Dyscalculia
- D. Dysphasia
Correct Answer: C
Rationale: Mathematics Disorder (Dyscalculia): A specific learning disability characterised by mathematical ability being substantially below norm for chronological age, intelligence, and educational level.
A child, aged 11 years, has to stay home from school to care for his siblings while his mother works, because the family cannot afford a babysitter. The father appears to be emotionally abusive. Which intervention could be used for the primary prevention of problems such as these?
- A. Involve the parents in a parenting support group, and help them find affordable childcare.
- B. Meet with elected officials to lobby for subsidized childcare and increasing the minimum wage.
- C. Screen for signs of abuse and neglect in all children so that it can be discovered and treated early.
- D. Provide supportive counseling services for those who have survived neglect or abuse.
Correct Answer: B
Rationale: The correct answer is B because lobbying for subsidized childcare and increasing the minimum wage addresses the root causes of the family's situation, such as financial insecurity and lack of affordable childcare. This intervention aims to prevent similar situations from occurring by advocating for systemic changes that can support families in need.
Choice A focuses on providing support to the parents, which may not address the underlying issues of financial instability and emotional abuse. Choice C addresses detection and treatment after the abuse has occurred, rather than preventing it from happening in the first place. Choice D focuses on providing counseling services after abuse or neglect has already taken place, rather than preventing it through systemic changes like subsidized childcare and increased minimum wage.
A client with borderline personality disorder is having difficulty with memories of sexual abuse. She has a history of suicidal gestures, self-mutilation, sexual addiction, and substance addiction. She complains of vague pains, menstrual problems, and headaches. She entered the partial hospital program to prevent another suicide gesture or self-mutilation. The nurse recognizes that collaborative therapy may be helpful for this client and knows that the most useful collaboration in this case would be the client, the nurse, and the:
- A. Occupational therapist exploring ways to reduce stress
- B. Physical therapist exploring ways to reduce back pain
- C. Acupuncturist exploring ways to reduce pain
- D. Sexologist exploring healthy sexuality and safe sex
Correct Answer: A
Rationale: The correct answer is A: Occupational therapist exploring ways to reduce stress. In this case, the client's symptoms and history suggest complex emotional issues related to trauma and addiction. Occupational therapy can help the client develop coping skills, manage stress, and improve functioning in daily activities. The therapist can work collaboratively with the client and nurse to address the client's emotional, physical, and social needs.
Choice B: Physical therapist exploring ways to reduce back pain focuses only on physical symptoms and does not address the underlying emotional issues. Choice C: Acupuncturist exploring ways to reduce pain also only addresses physical symptoms and does not provide comprehensive support for the client's mental health. Choice D: Sexologist exploring healthy sexuality and safe sex is not the most immediate need for the client, as her primary concerns are related to trauma, self-harm, and addiction.
Attention Deficit Hyperactivity Disorder (ADHD) is equally common in boys and girls
- A. TRUE
- B. FALSE
Correct Answer: B
Rationale: ADHD is more commonly diagnosed in boys than girls, though it affects both genders.
A patient received maintenance doses of fluphenazine decanoate (Prolixin Decanoate) 25 mg IM every 2 weeks for 2 years. The clinic nurse notes the patient is grimacing and seems to be constantly smacking her lips. On the next clinic visit, the patient's neck and shoulders twist in a slow, snakelike motion. The nurse should suspect the presence of ______ and should ______.
- A. agranulocytosis"¦check the patient's complete blood count for changes
- B. tardive dyskinesia"¦administer the Abnormal Involuntary Movement Scale
- C. Tourette's syndrome"¦consult the patient's physician about a neuro evaluation
- D. anticholinergic effects"¦consult the physician about possible medication changes
Correct Answer: B
Rationale: The correct answer is B: tardive dyskinesia"¦administer the Abnormal Involuntary Movement Scale.
1. Tardive dyskinesia is a side effect of long-term use of antipsychotic medications like fluphenazine.
2. The symptoms described - grimacing, lip smacking, twisting neck and shoulders - are characteristic of tardive dyskinesia.
3. Administering the Abnormal Involuntary Movement Scale is the appropriate assessment tool for diagnosing tardive dyskinesia.
4. Agranulocytosis (choice A) is a rare but serious side effect of some antipsychotic medications, not associated with the symptoms described.
5. Tourette's syndrome (choice C) typically presents with vocal and motor tics, not the specific symptoms mentioned.
6. Anticholinergic effects (choice D) can cause dry mouth, constipation, and blurred vision, but not the involuntary movements described.