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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 and get lost. Placing locks at the tops of exterior doors can help prevent the client from leaving the house unsupervised, reducing the risk of harm. Other choices are incorrect because: A: Replacing carpet with hardwood floors may not directly address safety concerns. B: Encouraging physical activity prior to bedtime may disrupt sleep patterns. C: Wearing clothing with zippers instead of buttons is a personal preference and not directly related to safety.
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A nurse is providing teaching to a client who has a depressive disorder and a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching?
- A. I can continue to take St. John's wort while taking this medication.
- B. I know it will be a couple of weeks before the medication helps me feel better.
- C. I expect this medication to raise my blood pressure.
- D. I should take this medication on an empty stomach.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
- Choice B indicates an understanding of the delayed onset of action of amitriptyline, which typically takes a couple of weeks to produce therapeutic effects.
- This knowledge is crucial for managing client expectations and adherence to treatment.
- Choices A, C, and D are incorrect:
- A: Taking St. John's wort with amitriptyline can result in serotonin syndrome due to potential drug interactions.
- C: Amitriptyline can actually lower blood pressure, not raise it.
- D: Amitriptyline is usually taken with food to minimize gastrointestinal side effects.
- In summary, choice B reflects the correct understanding of the medication's timeline for efficacy, while the other choices demonstrate misconceptions or potential risks.
A nurse is admitting a client who has dementia to a long-term care facility. The client tells the nurse that she lived in this facility years ago and took care of all the residents by herself. The nurse should document this as which of the following findings?
- A. Projection
- B. Perseveration
- C. Agnosia
- D. Confabulation
Correct Answer: D
Rationale: The correct answer is D: Confabulation. Confabulation is the unintentional fabrication of memories or events to fill in gaps in memory due to cognitive impairment. In this scenario, the client with dementia is creating false memories of taking care of all the residents by herself, which is a classic example of confabulation. This behavior is not intentional lying but a result of memory deficits.
Choice A: Projection involves attributing one's own unacceptable feelings or thoughts to others, which is not applicable in this context.
Choice B: Perseveration is the repetition of a particular response, such as repeating a word or phrase, which does not align with the client's false memory.
Choice C: Agnosia refers to the inability to recognize familiar objects or people due to brain damage, which is not evident in the client's statement.
A nurse is admitting a client who has schizophrenia. The client states, "I'm hearing voices." Which of the following responses is the priority for the nurse to state?
- A. "What are the voices telling you?"
- B. "I realize the voices are real to you, but I don't hear anything."
- C. "Have you taken your medication today?"
- D. "How long have you been hearing the voices?"
Correct Answer: A
Rationale: The correct answer is A: "What are the voices telling you?" This response demonstrates active listening, assesses the content of the hallucinations, and helps the nurse understand the client's experience. It allows for further assessment and intervention planning. Choice B dismisses the client's experience, choice C focuses on medication compliance rather than addressing the immediate concern, and choice D addresses the duration of the hallucinations but doesn't address the current situation.
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 in an acute mental health care facility is prioritizing care for multiple clients. Which of the following clients should the nurse see first?
- A. A client who has narcissistic personality disorder and is mocking others during group therapy
- B. A client who has obsessive-compulsive disorder and is upset about a change in daily routine
- C. A client who has depressive disorder and requires assistance with ADLs
- D. A client who is taking clozapine to treat schizophrenia and reports a sore throat
Correct Answer: D
Rationale: The correct answer is D. The nurse should see the client taking clozapine first due to the potential side effect of agranulocytosis, which can manifest as a sore throat. This is a serious adverse effect that requires immediate attention to prevent complications. The other clients do not present with urgent or life-threatening issues. A: Narcissistic behavior is disruptive but not a medical emergency. B: Upset about a routine change is distressing but does not pose a physical health risk. C: Assistance with ADLs is important but not immediately life-threatening. Therefore, prioritizing the client on clozapine with a sore throat is crucial to ensure timely intervention and prevent serious complications.