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A home health nurse is planning care for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?
- A. Replace the carpet with hardwood floors.
- B. Encourage physical activity prior to bedtime.
- C. Wear clothing with zippers instead of buttons.
- D. Place locks at the tops of exterior doors.
Correct Answer: D
Rationale: The correct answer is D: Place locks at the tops of exterior doors. This is important for the safety of a client with Alzheimer's disease who may wander. Placing locks at the tops of doors can prevent the client from easily opening them and wandering off, which is a common behavior in Alzheimer's patients.
A: Replacing carpet with hardwood floors may not directly address the safety concern of wandering.
B: Encouraging physical activity prior to bedtime may help with sleep but does not address the safety issue of wandering.
C: Wearing clothing with zippers instead of buttons may be easier for the client to manage, but it does not address the safety concern of wandering.
Summary: The key consideration in caring for a client with Alzheimer's disease is ensuring their safety, particularly in preventing wandering, which is why placing locks at the tops of exterior doors is the most appropriate action.
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A nurse is speaking with the caregiver of a client who has Alzheimer's disease. The caregiver states, "Providing constant care is very stressful and is affecting all areas of my life." Which of the following actions should the nurse take?
- A. Suggest that the caregiver seek a prescription for an antipsychotic medication for the client.
- B. Recommend allowing the client to have time alone in their room throughout the day.
- C. Discuss methods of how to communicate with the client about resolving problem behaviors.
- D. Assist the caregiver to arrange for a daycare program for the client.
Correct Answer: D
Rationale: The correct answer is D: Assist the caregiver to arrange for a daycare program for the client. This option addresses the caregiver's need for respite and support, allowing them to take a break from constant care. It promotes the client's social engagement and activities in a safe environment, offering the caregiver time to attend to their own needs. This option recognizes the importance of caregiver well-being in managing the stress associated with caring for a client with Alzheimer's disease.
Incorrect options:
A: Suggesting antipsychotic medication for the client is not appropriate without further assessment and should not be the first intervention.
B: Allowing the client time alone does not address the caregiver's need for support and respite.
C: Discussing communication methods is important, but it doesn't directly address the caregiver's need for relief from constant care.
E, F, G: Not provided in the question.
A nurse in an outpatient mental health clinic is assessing an adolescent client. The nurse should expect the adolescent to be in which of the following of Erikson's stages of psychosocial development?
- A. Generativity vs self-absorption
- B. Trust vs mistrust
- C. Intimacy vs isolation
- D. Identity vs role confusion
Correct Answer: D
Rationale: The correct answer is D: Identity vs role confusion. Adolescents typically fall into this stage, characterized by exploring and establishing their sense of self and identity. They may question their roles and values, seeking to understand who they are. Choice A (Generativity vs self-absorption) is more relevant to middle adulthood. Choice B (Trust vs mistrust) is for infancy. Choice C (Intimacy vs isolation) is for young adulthood.
A nurse in a mental health clinic receives a request from a client who is undergoing psychotherapy to obtain a copy of the therapist's notes. Which of the following responses should the nurse make?
- A. "Are you not happy with your treatment?"
- B. "We can provide a copy of your records, but the therapist's notes are not included."
- C. "Why are you interested in seeing your therapist's notes?"
- D. "I don't think you will benefit from reviewing your therapist's notes right now."
Correct Answer: B
Rationale: The correct answer is B because therapist's notes are considered privileged information and are not typically included in a client's medical records. Providing these notes could compromise the therapeutic relationship and confidentiality. Option A is incorrect as it assumes the client is unhappy with treatment. Option C is inappropriate as it questions the client's motivation. Option D is incorrect as it dismisses the client's request without proper justification. Options E, F, and G are not provided, but B is the most appropriate response in this scenario.
A nurse is caring for a client who has alcohol use disorder and is experiencing withdrawal. Which of the following medications should the nurse expect to administer?
- A. Methadone
- B. Disulfiram
- C. Lorazepam
- D. Bupropion
Correct Answer: C
Rationale: The correct answer is C: Lorazepam. Lorazepam is a benzodiazepine used to manage alcohol withdrawal symptoms by reducing anxiety, seizures, and agitation. Methadone (A) is used for opioid addiction, Disulfiram (B) is for alcohol aversion therapy, and Bupropion (D) is for smoking cessation. The other choices are not appropriate for alcohol withdrawal management.
A nurse is planning care for a client who has borderline personality disorder and engages in self-mutilation. Which intervention should the nurse include?
- A. Restrict the client's access to personal belongings.
- B. Encourage the client to express feelings of anger.
- C. Place the client in seclusion when self-injurious behavior occurs.
- D. Tell the client to stop the self-mutilation behavior.
Correct Answer: B
Rationale: The correct answer is B: Encourage the client to express feelings of anger. This intervention helps the client explore and process underlying emotions contributing to self-mutilation. It promotes emotional awareness and healthy coping mechanisms. Restricting personal belongings (A) may escalate feelings of frustration. Seclusion (C) can be traumatic and worsen abandonment fears. Telling the client to stop (D) oversimplifies a complex issue and may lead to resistance.