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An older adult client who appears alert, oriented, and well-groomed shares with the nurse, 'Lately, I am seeing things that are not there. It is always people. I am awake and sitting down and I know they are not there, but I see them.' Which response by the nurse is appropriate?
- A. Has anyone in your family ever been diagnosed with schizophrenia?
- B. What medications have you been taking recently?
- C. Don't worry. You may actually have been asleep and dreaming.
- D. The Alzheimer organization offers some tests you may want to take.
Correct Answer: B
Rationale: Inquiring about medications explores potential causes of hallucinations, such as side effects, which is a common issue in older adults. Schizophrenia or Alzheimer’s assumptions are premature, and dismissing as dreaming ignores the client’s awareness.
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A client diagnosed with empyema is to undergo decortication to remove inflamed tissue, pus, and debris. On the basis of which understanding about this procedure should the nurse offer emotional support to the client?
- A. This problem may decrease the client's life expectancy.
- B. The client is likely to be in excruciating pain after surgery.
- C. The client will probably have chronic dyspnea after the surgery.
- D. Chest tubes will be in place after surgery, and the healing process is slow.
Correct Answer: D
Rationale: The client undergoing decortication to treat empyema needs ongoing support from the nurse. This is especially true because the client will have chest tubes in place after surgery, and these must remain until the former pus-filled space is completely obliterated. This may take some time, and it may be discouraging to the client. Progress is monitored by chest x-ray. This information supports that the remaining options are not accurate.
A preschooler has just been diagnosed with impetigo. The child's mother tells the nurse, 'But my children take baths every day.' Which therapeutic response should the nurse make to the mother?
- A. You are concerned about how your child got impetigo?'
- B. There is no need to worry. We will not tell your day care provider why your child is absent.'
- C. Not only do you have to do a better job of keeping your children clean, you must also wash your hands more frequently.'
- D. You should have seen the doctor before the wound became infected, and then you would not have had to worry about the child having impetigo.'
Correct Answer: A
Rationale: By paraphrasing what the parent tells the nurse, the nurse is addressing the parent's thoughts. Option 1 demonstrates the therapeutic technique of paraphrasing. The remaining options are blocks to communication because they make the parent feel guilty for the child's illness.
The nurse provides care for a client diagnosed with Korsakoff psychosis. Which assessment finding does the nurse expect?
- A. The client's blood pressure is 180/96 mm Hg.
- B. The client has right-sided weakness.
- C. The client has tinnitus.
- D. The client invents elaborate, improbable events.
Correct Answer: D
Rationale: Korsakoff psychosis, often linked to chronic alcoholism, is characterized by confabulation, where clients invent elaborate but false events to fill memory gaps. Hypertension, weakness, or tinnitus are not specific to this condition.
The nurse is caring for a client with schizophrenia who is having active hallucinations. The nurse implements which actions to manage the client during the episode? Select all that apply.
- A. administers medications as ordered
- B. uses gentle touch to reassure the client
- C. tells the client that others see or hear what he does
- D. distracts the client by placing him in the dayroom with others
- E. asks the client if he hears voices telling him to harm himself or others
Correct Answer: A,E
Rationale: Administering medications (A) helps manage hallucinations, and asking about harmful voices (E) assesses safety. Touch (B) may be misinterpreted, validating hallucinations (C) is harmful, and distraction in a dayroom (D) may overwhelm the client.
The nurse is caring for an elderly female client who presents as being alert and oriented. In the late afternoon, the client becomes extremely agitated and confused. Which of the following responses by the nurse is most appropriate?
- A. call a family member to come and stay with the client
- B. call the health care provider and ask for an order for Xanax
- C. reorient the client and offer distraction and reassurance in a soft voice
- D. tell the client that if she does not cooperate, she will be placed in restraints
Correct Answer: C
Rationale: This behavior suggests sundowning, common in elderly clients. Reorientation and reassurance are appropriate non-pharmacological interventions.