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 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.
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A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan?
- A. Encourage the client to lie down in a quiet room.
- B. Refer to the hallucinations as if they are real.
- C. Ask the client directly what he is hearing.
- D. Avoid eye contact with the client.
Correct Answer: C
Rationale: The correct answer is C: Ask the client directly what he is hearing. This action is crucial in assessing the content and severity of the hallucinations, which helps in tailoring appropriate interventions. By directly inquiring about the auditory hallucinations, the nurse demonstrates active listening and shows empathy towards the client's experiences. This approach also fosters a trusting therapeutic relationship.
Choice A: Encouraging the client to lie down in a quiet room does not address the auditory hallucinations directly and may not be effective in managing them.
Choice B: Referring to the hallucinations as if they are real can validate and reinforce the client's delusions, worsening the symptoms.
Choice D: Avoiding eye contact with the client may convey a message of discomfort or disinterest, hindering the establishment of rapport and trust.
In summary, choice C is the most appropriate as it directly addresses the client's symptoms and facilitates a comprehensive assessment, which is essential for developing an effective care plan.
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 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 and reporting a sore throat first due to the potential side effect of agranulocytosis. This is a serious adverse effect of clozapine that can lead to life-threatening infections, making it a priority to assess and address promptly. The other choices do not present immediate life-threatening concerns. Choice A involves behavior management that can be addressed later. Choice B involves distress but not immediate physical risk. Choice C involves assisting with activities of daily living which can be managed after addressing the urgent medical concern of the client on clozapine.
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 planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)
- A. Give the client one simple direction at a time.
- B. Refute the client's delusions using logic.
- C. Allow the client to choose among a variety of activities each day.
- D. Reinforce orientation to time, place, and person.
- E. Establish eye contact when communicating with the client.
Correct Answer: A, D, E
Rationale: Correct Answer: A, D, E
Rationale:
A: Giving the client one simple direction at a time is important as individuals with dementia may have difficulty processing complex information.
D: Reinforcing orientation to time, place, and person helps maintain the client's sense of reality and reduce confusion.
E: Establishing eye contact when communicating with the client promotes engagement and helps in maintaining their attention.
Summary:
B: Refuting the client's delusions using logic can be counterproductive as it may cause distress and worsen their symptoms.
C: Allowing the client to choose among a variety of activities may overwhelm them. It is better to provide structured activities.
F & G: Not applicable.