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A nurse is caring for a client who has an anxiety disorder and who has begun to hyperventilate, wring her hands, and is pacing the floor continually. Which of the following actions should the nurse take first?
- A. Tell the client you will remain with her.
- B. Take the client to a quiet room.
- C. Ask the client what precipitated this anxiety
- D. Offer the client a prescribed anxiety medication
Correct Answer: A
Rationale: Reassuring presence stabilizes the client emotionally, addressing immediate distress. A quiet room helps but follows reassurance. Asking about triggers is secondary to calming the client. Medication may be needed, but support comes first.
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An elderly client with severe cardiovascular disease is given the diagnosis of dementia. Which type of dementia does the client most likely have?
- A. Frontal
- B. Lewy body
- C. Alzheimer's
- D. Vascular dementia
Correct Answer: D
Rationale: Frontal (frontotemporal) dementia affects personality and behavior, not directly tied to cardiovascular issues. Lewy body dementia involves protein deposits and symptoms like hallucinations, not primarily cardiovascular-related. Alzheimer’s is common but linked to neurodegenerative changes, not specifically cardiovascular disease. Vascular dementia results from impaired blood flow to the brain, often due to cardiovascular conditions, making it the most likely here.
A hospitalized client sees snakes on the walls of the hospital room and becomes anxious. This is an example of which of the following?
- A. Hallucinations
- B. Delirium
- C. Delusion
- D. Psychosis
Correct Answer: A
Rationale: Hallucinations involve perceiving things that aren’t present, like seeing snakes, fitting the client’s experience. Delirium is a broader state of confusion that may include hallucinations but isn’t specific to this symptom alone. Delusions are false beliefs, not perceptions. Psychosis is a general term that can include hallucinations but isn’t as precise as the specific symptom described.
A client with generalized anxiety disorder (GAD) is prescribed buspirone (BuSpar). Which information regarding side effects should be given to the client?
- A. The medication may cause cardiac arrest.
- B. Drink adequate amounts of fluid to prevent constipation
- C. The medication will not affect your vision.
- D. The risk of sedation is increased with this medication.
Correct Answer: B
Rationale: Cardiac arrest is not a common side effect of buspirone; it’s a rare and extreme outcome not typically associated with this medication. Buspirone can cause gastrointestinal side effects like constipation, so advising the client to drink adequate fluids helps mitigate this risk and supports overall health. There is no evidence that buspirone significantly affects vision as a common side effect, but this isn’t the most critical information to share. Buspirone is less sedating compared to other anxiolytics like benzodiazepines, so warning about increased sedation would be inaccurate.
A nurse in an assisted-living facility is caring for a client who is in early stages of dementia. The client has been oriented to name and place and is usually cooperative. Which of the following nursing actions is appropriate if the client refuses to take morning medications?
- A. Notify the charge nurse of the need for evaluation of the client's level of competence.
- B. Ask the client to express her reasons for refusing the morning medications and document the event.
- C. Crush the pills, if not contraindicated, and hide them in the client's applesauce.
- D. Try to talk the client into adherence by telling her the possible implications of missing a dose.
Correct Answer: B
Rationale: Competence evaluation follows understanding refusal. Asking reasons respects autonomy and informs care. Crushing pills without consent is unethical and risky. Coercion dismisses client rights; understanding is better.
Which therapeutic intervention would the nurse include in a care plan for a client with Alzheimer's disease?
- A. Avoid exercise because of the risk of falls.
- B. Frequently orient to time, place, and person
- C. Place client in group therapy with about 10
- D. Provide a stimulating environment.
Correct Answer: B
Rationale: Exercise benefits Alzheimer’s clients, reducing fall risk with supervision. Frequent orientation maintains cognition and security. Large groups overwhelm due to cognitive limits. Over-stimulation causes confusion; moderate stimulation is better.