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A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?
- A. Rotate assignment of daily caregivers.
- B. Provide an activity schedule that changes from day to day.
- C. Limit time for the client to perform activities.
- D. Talk the client through tasks one step at a time.
Correct Answer: D
Rationale: Clients with Alzheimer's benefit from structured routines and step-by-step guidance.
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A nurse is admitting a client who is in the manic phase of bipolar disorder. The nurse should plan to make which of the following room assignments for the client?
- A. A private room in a quiet location on the unit
- B. A semiprivate room with a roommate who has similar symptoms
- C. A private room close to the nursing station
- D. A seclusion room until the client's activity level becomes more subdued
Correct Answer: C
Rationale: The correct answer is C: A private room close to the nursing station. This choice ensures the client's safety and allows for close monitoring by the nursing staff due to the increased risk of impulsive behaviors during the manic phase. A private room helps minimize distractions and stimuli that can exacerbate manic symptoms, while proximity to the nursing station enables quick intervention if needed.
Incorrect choices:
A: A private room in a quiet location on the unit - While privacy is important, a quiet location may not provide adequate supervision and support for a client in the manic phase.
B: A semiprivate room with a roommate who has similar symptoms - Sharing a room with someone exhibiting similar symptoms may lead to escalation of behaviors and lack of supervision.
D: A seclusion room until the client's activity level becomes more subdued - Seclusion should only be used as a last resort for safety concerns and is not appropriate for managing manic symptoms.
A nurse is reinforcing teaching about alcohol tolerance with a newly admitted client. Which of the following statements by the client indicates understanding?
- A. Alcohol tolerance produces physical changes when I haven't recently ingested alcohol.'
- B. Alcohol tolerance causes me to have an increased effect when taking opiates.'
- C. I will develop a decreased physical response to alcohol.'
- D. Alcohol tolerance is a medical emergency and can develop as a result of withdrawal.'
Correct Answer: C
Rationale: The correct answer is C: "I will develop a decreased physical response to alcohol." This statement indicates understanding of alcohol tolerance, where the body becomes less responsive to the effects of alcohol over time, requiring larger amounts to achieve the same effect. Choice A is incorrect as alcohol tolerance actually leads to a decreased response, not physical changes when alcohol is not consumed. Choice B is incorrect as alcohol tolerance does not affect the response to opiates. Choice D is incorrect as alcohol tolerance is not a medical emergency; it is a gradual adaptation to alcohol consumption.
A nurse manager is providing staff education about working with clients who have a history of anger and aggression. Which of the following information should the nurse include in the teaching? (Select all that apply.)
- A. Avoid wearing necklaces during client care.
- B. Know the layout of the facility.
- C. Stand directly in front of the client when talking.
- D. Bring security with you for all client interactions.
- E. Provide immediate verbal feedback for escalating behavior.
Correct Answer: A, B, E
Rationale: The correct answers are A, B, and E. A: Wearing necklaces can be used as a weapon or trigger aggressive behavior. B: Knowing the facility layout helps in planning safe exits during an escalating situation. E: Providing immediate verbal feedback can help de-escalate aggressive behavior. C: Standing directly in front of the client can be confrontational. D: Bringing security for all interactions may escalate tension unnecessarily.
A nurse is assessing a parent who lost a 12-year-old child in a car crash 2 years ago. Which of the following findings indicates the client is exhibiting manifestations of prolonged grieving?
- A. Leaves the child's room exactly as it was before the loss
- B. Volunteers at a local children's hospital
- C. Talks about the child in the past tense
- D. Visits the child's grave every week after worship services
Correct Answer: A
Rationale: In prolonged grief, individuals may struggle to move forward and avoid changing their environment.
A nurse is teaching a newly-admitted client about the possible physical effects of alcohol withdrawal. Which of the following manifestations should the nurse include in the teaching? (Select all that apply.)
- A. Seizures
- B. Illusions
- C. Tremors
- D. Polyphagia
- E. Nystagmus
Correct Answer: A, B, C
Rationale: Answer: A, B, C are correct.
Rationale:
A: Seizures can occur during alcohol withdrawal due to CNS hyperexcitability.
B: Illusions are common manifestations due to altered sensory perception.
C: Tremors are a classic sign of alcohol withdrawal due to CNS hyperactivity.
Summary:
D: Polyphagia (excessive hunger) is not a typical physical effect of alcohol withdrawal.
E: Nystagmus (involuntary eye movements) is not commonly associated with alcohol withdrawal.