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A nurse in a long-term care facility is caring for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?
- A. Post a written schedule of daily activities
- B. Use an overhead loudspeaker to announce events
- C. Provide a consistent daily routine
- D. Allow the client to choose free-time activities
Correct Answer: C
Rationale: The correct answer is C: Provide a consistent daily routine. Individuals with Alzheimer's disease benefit from a structured routine as it helps reduce confusion and anxiety. Consistency in daily activities can enhance familiarity and comfort for the client, promoting a sense of security and predictability. This routine can also aid in maintaining the client's cognitive function and overall well-being.
Incorrect choices:
A: Post a written schedule of daily activities - While this may be helpful, a consistent routine is more effective in providing stability for individuals with Alzheimer's.
B: Use an overhead loudspeaker to announce events - Loud noises and sudden announcements can be overwhelming for individuals with Alzheimer's, causing distress.
D: Allow the client to choose free-time activities - While promoting autonomy is important, too many choices can lead to confusion and difficulty in decision-making for individuals with Alzheimer's.
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A nurse is caring for a client who has a depressive disorder. The client states, "I just can't feel any happiness or joy in life." Which of the following terms should the nurse use when documenting this finding?
- A. Anhedonia
- B. Anergia
- C. Anosognosia
- D. Akathisia
Correct Answer: A
Rationale: The correct answer is A: Anhedonia. Anhedonia refers to the inability to experience pleasure or joy, which is a common symptom of depressive disorders. In this case, the client's statement of not feeling happiness or joy directly aligns with the definition of anhedonia.
Choice B, Anergia, refers to lack of energy or motivation, which is not directly related to the client's statement about not feeling happiness or joy. Choice C, Anosognosia, is a lack of awareness or insight into one's own condition, which is not applicable in this scenario. Choice D, Akathisia, refers to a movement disorder characterized by restlessness, which is not related to the client's emotional state.
In summary, Anhedonia is the most appropriate term to use when documenting the client's inability to feel happiness or joy, as it directly reflects their emotional experience in the context of a depressive disorder.
A nurse is caring for a 9-year-old boy who has a new diagnosis of diabetes mellitus and is eager to return to school and participate in social events. The mother tells the nurse she is afraid to let him take part in physical activities at school. Which of the following responses should the nurse make?
- A. "Tell me more about how you are feeling about your son's activities!"
- B. "You might want to use tutors to home-school him."
- C. "I agree. His well-being is the most important."
- D. "You sound overprotective. Let's talk about this some more."
Correct Answer: A
Rationale: The correct response is A: "Tell me more about how you are feeling about your son's activities!" This response demonstrates active listening and empathy, allowing the mother to express her concerns and fears openly. By understanding her perspective, the nurse can provide tailored education and support to address her specific worries regarding her son's activities. This approach fosters trust and collaboration between the nurse and the mother, leading to a more effective care plan for the child.
Incorrect responses:
B: "You might want to use tutors to home-school him." - This response does not address the mother's concerns directly and suggests an extreme solution without exploring the root of her fears.
C: "I agree. His well-being is the most important." - While well-being is essential, this response does not invite further discussion or address the mother's specific worries.
D: "You sound overprotective. Let's talk about this some more." - This response may come off as judgmental and dismissive of the mother's
A nurse at a college campus mental health counseling center is caring for a student who just failed an examination. The student spends the session berating the teacher and the course. The nurse should recognize this behavior as which of the following defense mechanisms?
- A. Conversion
- B. Projection
- C. Undoing
- D. Regression
Correct Answer: B
Rationale: Projection involves attributing one’s own feelings or faults to others.
A community health nurse is providing teaching to the family of a client who has primary dementia. Which of the following manifestations should the nurse tell the family to expect?
- A. Decreased auditory and visual acuity
- B. Decreased display of emotions
- C. Personality traits that are opposite of original traits
- D. Forgetfulness gradually progressing to disorientation
Correct Answer: D
Rationale: Dementia typically presents with progressive forgetfulness and eventual disorientation.
A nurse is caring for a client who has been diagnosed with obsessive-compulsive disorder (OCD) and is constantly picking up after others in the day room. The nurse should recognize that the client uses this behavior to do which of the following?
- A. Limit the amount of time available to interact with others
- B. Focus attention on meaningful tasks
- C. Manipulate and control others’ behaviors
- D. Decrease anxiety to a tolerable level
Correct Answer: D
Rationale: The correct answer is D: Decrease anxiety to a tolerable level. In OCD, repetitive behaviors like picking up after others serve to reduce anxiety stemming from obsessive thoughts. This behavior acts as a coping mechanism to alleviate distress. Choice A is incorrect as the behavior is driven by anxiety, not a desire to limit interaction time. Choice B is incorrect as the behavior is not necessarily meaningful but rather a compulsive act. Choice C is incorrect as the behavior is self-directed, not aimed at controlling others.