Nokea
A nurse is caring for a client who has late-stage Alzheimer's disease and is hospitalized for treatment of pneumonia. During the night shift, the client is found climbing into the bed of another client who becomes upset and frightened. Which of the following actions should the nurse take?
- A. Assist the client to the correct room.
- B. Place the client in restraints.
- C. Reorient the client to time and place.
- D. Move the client to a room at the end of the hall.
Correct Answer: A
Rationale: Redirecting the client to their correct room is the least restrictive intervention while ensuring safety.
You may also like to solve these questions
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 client who has a new diagnosis of human immunodeficiency virus (HIV). He states, "I don't care what the doctors say, there is no way I can have HIV, and I don't need treatment for something I don't have." The nurse identifies that the client is experiencing which of the following types of crisis?
- A. Adventitious
- B. Internal
- C. Maturational
- D. Situational
Correct Answer: D
Rationale: The correct answer is D: Situational crisis. The client's denial of the HIV diagnosis and refusal of treatment indicate an acute crisis triggered by a specific event or situation - the new HIV diagnosis. In a situational crisis, individuals struggle to cope with a sudden and unexpected event, leading to cognitive dissonance and emotional distress. The client's disbelief and avoidance of the reality of the diagnosis demonstrate a maladaptive response to the crisis. Adventitious crisis (A) refers to events like natural disasters, which are not applicable here. Internal crisis (B) involves inner conflicts, not evident in this scenario. Maturational crisis (C) arises from developmental life stages, which is not the case here.
A nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain?
- A. The partner has placed locks at the top of the doors leading to the outside.
- B. The partner has hired a house cleaner.
- C. The partner has lost 20 lb in the past 2 months.
- D. The partner redirects the client when the client is frustrated.
Correct Answer: C
Rationale: The correct answer is C because the partner losing 20 lb in the past 2 months indicates caregiver role strain. Significant weight loss can be a sign of stress, neglecting self-care, and being overwhelmed by caregiving responsibilities. This observation suggests that the partner may not be prioritizing their own well-being while caring for the client with Alzheimer's disease.
Choice A is incorrect because placing locks at the top of doors is a safety measure commonly taken to prevent the client with Alzheimer's disease from wandering outside unsupervised. Choice B is incorrect as hiring a house cleaner can be a practical solution to manage household tasks and does not necessarily indicate caregiver role strain. Choice D is incorrect because redirecting the client when frustrated is a positive caregiving technique to manage challenging behaviors.
A nurse is caring for a client who has a history of alcohol use disorder and has been hospitalized for detoxification. The nurse enters the room and finds the client shouting in a terrified voice, "Get these bugs off of me!” Which of the following responses by the nurse is appropriate?
- A. "I'm sure that the bugs you see will not harm you."
- B. "Tell me more about the bugs that you see in your room."
- C. "I don't see any bugs, but you seem very frightened."
- D. "I do not see anything. This is part of the withdrawal process."
Correct Answer: C
Rationale: Response C is appropriate because it acknowledges the client's feelings without confirming the presence of bugs. This response shows empathy and understanding while not reinforcing the client's hallucination. Response A dismisses the client's fear and may increase anxiety. Response B encourages the client to focus on the hallucination, worsening the distress. Response D invalidates the client's experience and may lead to distrust.
A charge nurse is discussing suicide interventions with nursing staff. Which of the following should the nurse identify as an example of secondary intervention?
- A. Providing support for family and friends following a suicide.
- B. Identifying individuals who are at higher risk for attempting suicide.
- C. Recognizing the warning signs of suicide.
- D. Performing life-saving measures following a suicide attempt.
Correct Answer: D
Rationale: Secondary intervention involves direct care during a suicide crisis, such as life-saving measures.