Nokea
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.
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A nurse is caring for a client who has a history of opioid use disorder. Which medication should the nurse anticipate administering to prevent withdrawal symptoms?
- A. Methadone
- B. Disulfiram
- C. Naloxone
- D. Bupropion
Correct Answer: A
Rationale: The correct answer is A: Methadone. Methadone is a long-acting opioid agonist that helps manage withdrawal symptoms in clients with opioid use disorder. It reduces cravings and prevents withdrawal without causing euphoria. Disulfiram (B) is for alcohol use disorder, Naloxone (C) is an opioid antagonist used for opioid overdose reversal, and Bupropion (D) is an antidepressant and smoking cessation aid.
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, insomnia, and seizures. It helps stabilize the client during detoxification. Methadone (A) is used for opioid withdrawal, Disulfiram (B) is a deterrent for alcohol consumption, and Bupropion (D) is used for smoking cessation.
A nurse is caring for a client with major depressive disorder who has a new prescription for fluoxetine. Which statement by the client indicates an understanding of the medication?
- A. I should expect to see improvement in my mood within a few days.
- B. I may experience increased thoughts of suicide at the beginning of treatment.
- C. I need to avoid foods high in tyramine while taking this medication.
- D. I will need to have my lithium levels checked regularly.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Fluoxetine is an antidepressant that can initially increase suicidal thoughts in some individuals, especially at the beginning of treatment.
2. This phenomenon is known as "activation syndrome" and is important for clients to be aware of.
3. Monitoring for any signs of increased suicidal thoughts is crucial for client safety.
4. Options A, C, and D are incorrect because fluoxetine does not provide immediate mood improvement, does not require avoiding tyramine-rich foods, and does not affect lithium levels.
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 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 creation of false memories to fill in gaps in memory due to brain dysfunction. In this scenario, the client with dementia is creating a false memory about living in the facility and taking care of all the residents by herself. This is a common phenomenon in individuals with dementia as their ability to recall accurate memories is impaired.
A: Projection is a defense mechanism where one attributes their own feelings or thoughts to others.
B: Perseveration is the repetition of a particular response despite the absence or cessation of a stimulus.
C: Agnosia is the inability to recognize or interpret sensory information.
Summary: The other choices are incorrect because they do not specifically address the creation of false memories to compensate for memory deficits, which is characteristic of confabulation in individuals with dementia.