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A nurse is reinforcing teaching about home care with the family of a client who has Alzheimer's disease and wanders at night. Which of the following instructions should the nurse include?
- A. Keep the client's bedroom area dark at night.
- B. Have the client exercise 30 minutes before bedtime.
- C. Place the client's mattress on the bedroom floor.
- D. Encourage the client to nap often during the day.
Correct Answer: C
Rationale: Placing the client's mattress on the bedroom floor is a practical safety measure for clients with Alzheimer's disease who wander at night. This approach minimizes the risk of injury from falls, as the client will be closer to the ground. By reducing the height of the bed, families can create a safer sleeping environment and help prevent potential injuries due to wandering and confusion.
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A nurse is caring for a client who has chronic alcohol use disorder. Which of the following laboratory findings should the nurse monitor to evaluate the client's nutritional status?
- A. Serum creatinine.
- B. Thiamine level.
- C. Urinalysis.
- D. Erythrocyte sedimentation rate.
Correct Answer: B
Rationale: Thiamine (vitamin B1) deficiency is a well-known complication of chronic alcohol use disorder. Alcohol interferes with the absorption and utilization of thiamine, leading to deficiencies that can cause severe neurological problems, such as Wernicke's encephalopathy and Korsakoff's syndrome. Monitoring thiamine levels is crucial in assessing and managing the nutritional status of clients with chronic alcohol use disorder.
A nurse is caring for a client who has delirium. Which of the following findings should the nurse expect?
- A. Gradual onset
- B. Impaired judgment
- C. Difficulty swallowing
- D. Slowed, flat speech
Correct Answer: B
Rationale: Impaired judgment is a common finding in delirium. Clients with delirium often have fluctuating levels of consciousness, attention deficits, and disorganized thinking, all of which can contribute to poor judgment. This cognitive impairment can lead to unsafe behaviors and difficulty in making decisions.
A nurse in a mental health facility is contributing to the plan of care for a new client. Which of the following actions should the nurse plan to include in the working phase of the nurse-client relationship?
- A. Determine whether the client's goals are met.
- B. Collect data about the client's current health status.
- C. Provide the client with information on problem-solving.
- D. Establish a regular meeting time with the client.
Correct Answer: C
Rationale: Providing the client with information on problem-solving is an essential component of the working phase of the nurse-client relationship. During this phase, the nurse and client work collaboratively to address issues, develop coping strategies, and implement interventions aimed at improving the client's mental health.
A nurse is reinforcing teaching with a client who has generalized anxiety disorder and a new prescription for buspirone. Which of the following information should the nurse include?
- A. This medication is known to cause dependence.
- B. Avoid consuming large amounts of leafy, green vegetables while taking this medication.
- C. It can take several weeks before you notice an effect from the medication.
- D. If a dose is missed, you can take the missed dose along with the next scheduled dose.
Correct Answer: C
Rationale: Buspirone typically takes several weeks to achieve its full therapeutic effect. Clients should be advised to continue taking the medication as prescribed and not to expect immediate relief of anxiety symptoms. This information helps set realistic expectations and encourages adherence to the treatment plan.
A nurse is reinforcing teaching with a client who has a new prescription for a nicotine transdermal system. Which of the following statements should the nurse make?
- A. A decrease in appetite is expected when beginning treatment.
- B. Using this medication will help minimize symptoms of withdrawal.
- C. Expect to stop smoking immediately after starting this medication.
- D. Apply a new patch every 4 hours until your cravings diminish.
Correct Answer: B
Rationale: Nicotine replacement therapy, including the nicotine transdermal system, is designed to help minimize symptoms of nicotine withdrawal. These symptoms can include cravings, irritability, anxiety, and difficulty concentrating. By providing a controlled release of nicotine, the transdermal system helps reduce the intensity of withdrawal symptoms and supports the quitting process.