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A home health nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain?
- A. The partner has hired a house cleaner.
- B. The partner has placed locks at the top of the doors leading to the outside.
- C. The partner has lost 25 lb in the past 3 months.
- D. The partner redirects the client when the client is frustrated.
Correct Answer: C
Rationale: The correct answer is C because the partner losing 25 lb in the past 3 months indicates caregiver role strain. Weight loss can be a sign of stress and neglecting one's own needs while caring for someone with Alzheimer's. This choice reflects the physical toll caregiving can take.
A: Hiring a house cleaner (choice A) shows that the partner is seeking help and support, which is a positive coping strategy and does not necessarily indicate caregiver role strain.
B: Placing locks at the top of the doors (choice B) demonstrates safety measures for the client and does not directly indicate caregiver role strain.
D: Redirecting the client when frustrated (choice D) shows appropriate management of challenging behaviors and does not directly indicate caregiver role strain.
In summary, choice C is the best indicator of caregiver role strain as it reflects the physical impact of the caregiving responsibilities on the partner's well-being.
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The nurse is teaching a client about cellular hypertrophy. Which statement should be included in the teaching?
- A. It's uncontrolled proliferative cell growth that is cancerous.
- B. It's the enlargement of an organ or tissue from the increase in cell size.
- C. It's the wasting away of tissue or organs.
- D. It's the abnormal growth or development of cells.
Correct Answer: B
Rationale: The correct answer is B because cellular hypertrophy refers to the increase in the size of cells leading to the enlargement of an organ or tissue. This is a normal physiological response to increased demand or stress. Choice A is incorrect as uncontrolled proliferative cell growth leading to cancer is known as neoplasia, not hypertrophy. Choice C is incorrect as wasting away of tissue is termed as atrophy, not hypertrophy. Choice D is incorrect as abnormal cell growth or development is more indicative of dysplasia or metaplasia, not hypertrophy.
A nurse is caring for a newly admitted adolescent client. When asked to describe their social support system,the client responds My mom died last year, and I have been in foster care ever since. I don't have many friends. Which of the following actions should the nurse take?
- A. Tell the client that being in foster care can help with coping.
- B. Explain how grief support groups could increase coping and social support.
- C. Encourage the client to ask the provider for medication.
- D. Suggest using the internet as a source for finding supportive friends.
Correct Answer: B
Rationale: The correct answer is B. The nurse should explain how grief support groups could increase coping and social support. Grief support groups provide a safe space for individuals to share their experiences, receive empathy, and learn coping strategies. This is particularly important for the adolescent client who has experienced significant loss and lacks a strong social support system. By participating in a grief support group, the client can connect with others who have had similar experiences, feel understood, and build new supportive relationships. This intervention addresses the client's need for social support and coping mechanisms.
Choices A, C, and D are incorrect. A: Being in foster care may provide some support, but it does not address the client's specific need for coping with grief and building a social support system. C: Encouraging the client to ask for medication is not appropriate without first exploring non-pharmacological interventions. D: Suggesting the internet as a source for finding friends does not address the client's need for emotional support and may not
A nurse is admitting a client with a history of alcohol use disorder. The nurse is aware that which of the following are potential physical symptoms of alcohol withdrawal? (Select all that apply.)
- A. Seizures
- B. Tachycardia
- C. Hallucinations
- D. Tremors
- E. Hypotension
Correct Answer: A,B,C,D
Rationale: The correct answer is A, B, C, and D. Alcohol withdrawal can lead to seizures due to hyperexcitability of the nervous system. Tachycardia is common as alcohol withdrawal can cause increased heart rate and blood pressure. Hallucinations are possible due to disturbances in brain function. Tremors are a typical symptom of alcohol withdrawal, known as "the shakes." Choices E and F, hypotension and G, are not typically associated with alcohol withdrawal. In summary, the correct symptoms are related to central nervous system hyperactivity, while the incorrect choices are not commonly observed in alcohol withdrawal.
A client has made the decision to leave her alcoholic husband and reports feeling very depressed. Which of the following is a non-therapeutic statement by the nurse that demonstrates sympathy?
- A. You are feeling very depressed. I felt the same way when I decided to leave my husband.
- B. I can understand you are feeling depressed. It was a difficult decision. I'll sit with you.
- C. You seem depressed. It was a difficult decision to make. Would you like to talk about it?
- D. I know this is a difficult time for you. Would you like medication for anxiety?
Correct Answer: A
Rationale: The correct answer is A because the nurse is sharing her personal experience, which is not therapeutic as it shifts the focus from the client to the nurse's own experience. This can make the client feel unheard and invalidated. Choice B demonstrates empathy and offers support by acknowledging the client's feelings and offering to sit with them. Choice C also shows empathy and provides an opportunity for the client to talk. Choice D is non-therapeutic as it jumps to suggesting medication without exploring the client's emotions or needs.
Medical History
• Diagnosed with anorexia nervosa at age 16.
• Participated in a weight restoration program 1 year ago.
Vital Signs
1200:
• Blood pressure: 99/59 mm Hg
• Temperature: 36.6°C (97.9°F)
• Heart rate: 58/min
• Respiratory rate: 20/min
• Oxygen saturation: 99% on room air
• Weight: 44.5 kg (98.1 lb)
• BMI: 18.5
• Height: 165.1 cm (65 in)
Nurses’ Notes
1200:
• 18-year-old client admitted to inpatient psychiatric unit after passing out at home. Client reports using laxatives and “making myself throw up after eating” for about 6 months.
1330:
• Reviewed client’s medical record and new diagnostic results; determined client is at risk for further health issues.
Diagnostic Results
1330:
• Basic metabolic panel:
o Glucose: 72 mg/dL (74 to 106 mg/dL)
o Calcium: 10.5 mg/dL (9 to 10.5 mg/dL)
o Sodium: 130 mEq/L (136 to 145 mEq/L)
o Potassium: 3.5 mEq/L (3.5 to 5 mEq/L)
o Magnesium: 2.2 mEq/L (1.3 to 2.1 mEq/L)
o Chloride: 100 mEq/L (98 to 106 mEq/L)
o BUN: 31 mg/dL (10 to 20 mg/dL)
o Creatinine: 3.0 mg/dL (0.5 to 1.0 mg/dL)
• Additional labs:
o Thyroxine, free (T4): 0.4 ng/dL (0.8 to 2.8 ng/dL)
A nurse is reviewing the medical record of a client. Exhibits Drag words from the choices below to fill in each blank in the following sentence.
The client is at risk for developing ----------------- and --------------------
.
- A. Heart Failure
- B. Renal Failure
- C. Hypomagnesemia
- D. Hypothyroidism
Correct Answer: B,D
Rationale:
The correct answer is B and D. Renal failure and hypothyroidism are conditions that can put a client at risk for developing various health issues. Renal failure can lead to electrolyte imbalances and fluid overload, increasing the risk of heart failure. Hypothyroidism can affect metabolism and cardiovascular function, also contributing to the risk of heart failure. Hypomagnesemia (choice C) is a condition characterized by low levels of magnesium in the blood and can lead to symptoms like muscle weakness and cardiac arrhythmias; however, it is not directly mentioned as a risk factor in the sentence provided. Heart failure (choice A) is a consequence or potential outcome of the conditions mentioned but is not specifically stated as a risk the client is currently facing in the sentence.