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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.
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A nurse in a hospital is caring for a client who has agoraphobia. Which of the following statements by the client indicates understanding of the goals of treatment?
- A. "I plan to sit on a park bench for a few minutes each day."
- B. "I can try participating in group therapy every week."
- C. "I will join a book club in my neighborhood."
- D. "I should avoid entering elevators and other closed spaces."
Correct Answer: A
Rationale: The correct answer is A: "I plan to sit on a park bench for a few minutes each day." This statement indicates the client's understanding of gradual exposure therapy, a common treatment for agoraphobia. Exposure to feared situations in a controlled manner helps desensitize the client to their anxiety triggers. Sitting on a park bench signifies a small step towards facing the fear of open spaces. Choices B, C, and D do not directly address the core issue of agoraphobia or the specific treatment approach. Group therapy and joining a book club may be beneficial but do not target the fear of open spaces. Avoiding elevators and closed spaces is a safety behavior that reinforces the fear and hinders recovery.
A nurse is caring for a client who has autism spectrum disorder. Which of the following findings should the nurse expect?
- A. Expressive affect
- B. Associative looseness
- C. Echolalia
- D. Ambivalence
Correct Answer: C
Rationale: Echolalia, or repeating words/phrases, is a common communication pattern in autism spectrum disorder.
A nurse is assessing a client experiencing chronic stress. Which of the following findings should the nurse expect?
- A. Hypotension
- B. Increased energy
- C. Increased cognitive awareness
- D. Hyperglycemia
Correct Answer: D
Rationale: The correct answer is D: Hyperglycemia. Chronic stress can lead to the release of stress hormones like cortisol and adrenaline, which can increase blood sugar levels. This occurs due to the body's fight-or-flight response to stress. Hypotension (A) is unlikely as stress typically leads to increased blood pressure. Increased energy (B) is less likely as chronic stress can lead to fatigue and exhaustion. Increased cognitive awareness (C) is not a common finding in chronic stress, as it can impair cognitive function. Hyperglycemia (D) is the most likely finding due to the physiological response to stress.
A nurse is admitting an older adult client who has a suspected cognitive disorder. Which of the following inventories should be included as part of the admission assessment?
- A. Mental Status Examination (MSE)
- B. Brief Patient Health Questionnaire (Brief PHQ)
- C. Abnormal Involuntary Movements Scale (AIMS)
- D. Scale for Assessment of Negative Symptoms (SANS)
Correct Answer: A
Rationale: The correct answer is A: Mental Status Examination (MSE). A MSE is crucial to assess cognitive function, orientation, memory, attention, and other mental aspects in older adults with suspected cognitive disorders. It helps identify cognitive deficits and guide appropriate interventions. Brief PHQ (B) focuses on mood disorders, AIMS (C) evaluates movement disorders, and SANS (D) assesses negative symptoms in psychiatric disorders, which are not specific to cognitive disorders. In summary, the MSE is the most relevant tool for assessing cognitive functions in this scenario.
A nurse is caring for a client who has dementia. When performing a Mental Status Examination (MSE), the nurse should include which of the following data? (Select all that apply.)
- A. Ability to perform calculations
- B. Coping skills
- C. Recall ability
- D. Long-term memory
- E. Level of orientation
Correct Answer: A, C, D, E
Rationale: The correct answers are A, C, D, and E. In a Mental Status Examination for a client with dementia, assessing the ability to perform calculations (A) is important to evaluate cognitive function. Recall ability (C) is crucial as memory impairment is a common feature of dementia. Long-term memory (D) is essential to assess for signs of cognitive decline. The level of orientation (E) is vital to determine the client's awareness of time, place, and person, which can be impaired in dementia. Coping skills (B) are important but not typically assessed in an MSE for dementia. The other choices (F, G) do not directly relate to the cognitive impairment typically seen in dementia.