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A home health nurse is visiting a client who has advanced Alzheimer's disease. The client's partner states, 'I miss being able to go places with my friends.' Which of the following is an appropriate response by the nurse?
- A. We can discuss this when you're not feeling overwhelmed.
- B. Have you tried taking your partner with you when you go out?
- C. Tell me more about your expectations.
- D. I understand how you feel. I've had a relative go through the same thing.
Correct Answer: C
Rationale: Asking about expectations opens dialogue and shows empathy, supporting the partner's needs.
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A nurse is participating in a group discussion about complicated grief associated with loss. Which of the following should the nurse identify as an example of exaggerated grief?
- A. A client whose grief response is repressed.
- B. A client whose grief response begins following a terminal diagnosis.
- C. A client whose grief response leads to self-destructive behaviors.
- D. A client whose grief response is triggered by a secondary loss.
Correct Answer: C
Rationale: Exaggerated grief involves intense, harmful reactions like self-destructive behaviors, impairing function.
A nurse is reinforcing teaching about end-of-life care with the partner of a client. Which of the following statements should the nurse make?
- A. Encourage your partner to eat three large meals each day.
- B. Opioids will be restricted if your partner develops respiratory distress.
- C. We will use an electric blanket to keep your partner warm.
- D. Assume your partner can hear you, even if they do not respond.
Correct Answer: D
Rationale: Hearing may persist, so speaking provides comfort and connection.
A nurse is collecting data from a client who reports feeling short of breath and notes that the client's SaO2 level is 88% while on room air. Which of the following actions should the nurse take first?
- A. Check the client's medical records to see which medications were recently administered.
- B. Review the client's most recent SaO2 level in the medical record.
- C. Notify the charge nurse of the client's condition.
- D. Recheck the client's SaO2 level after having the client cough and clear their throat.
Correct Answer: D
Rationale: Rechecking after coughing assesses if the low SaO2 is due to mucus, addressing it immediately.
A nurse is reinforcing teaching with a client who is about to start using a standard walker. Which of the following statements by the client indicates an understanding of the instructions?
- A. I'll keep my elbows slightly bent when I grasp the walker.
- B. I'll slide the walker and move it about a foot in front of me.
- C. I'll move the walker and my stronger leg ahead at the same time.
- D. I'll keep the height of my walker adjusted, so I lean slightly forward.
Correct Answer: A
Rationale: Slightly bent elbows ensure stability and comfort when using a walker.
A nurse is preparing to insert an indwelling urinary catheter and is verifying the client's express consent for this procedure. Which of the following actions should the nurse take?
- A. Obtain verbal consent from the client.
- B. Have another nurse co-sign the client's consent.
- C. Check the medical record for the client's signature on a previous consent form.
- D. Witness the client's signature on a consent form.
Correct Answer: D
Rationale: Witnessing the signature ensures informed consent for the procedure.