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Mrs. Jordan is an elderly client diagnosed with Alzheimer's disease. She becomes agitated and combative when a nurse approaches to help with morning care. The most appropriate nursing intervention in this situation would be to:
- A. tell the client firmly that it is time to get dressed.
- B. obtain assistance to restrain the client for safety.
- C. remain calm and talk quietly to the client.
- D. call the doctor and request an order for sedation.
Correct Answer: C
Rationale: When dealing with an elderly client with Alzheimer's disease who is agitated and combative, the most appropriate nursing intervention is to remain calm and talk quietly to the client. This approach can help soothe the client and prevent escalating the situation. Choice A is incorrect as being firm may further agitate the client. Choice B is inappropriate as restraining should only be used as a last resort for safety reasons and after other de-escalation techniques have been attempted. Choice D is not the best initial intervention and should only be considered after other non-pharmacological interventions have failed.
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Which of the following women are at highest risk for the development of endometrial cancer?
- A. A 50-year-old postmenopausal woman with a history of high-risk human papillomavirus
- B. A 45-year-old woman who is obese and has menstrual irregularities with periods of amenorrhea and infrequent periods.
- C. A 40-year-old woman who is overweight and has hypertension.
- D. A 55-year-old woman who smokes.
Correct Answer: B
Rationale: The correct answer is B. Obesity and irregular menstrual cycles, including periods of amenorrhea and infrequent periods, are significant risk factors for the development of endometrial cancer. Choice A is less likely as postmenopausal status reduces the risk. Choice C is not directly associated with a high risk of endometrial cancer. Choice D, smoking, is more strongly linked to other types of cancers like lung cancer rather than endometrial cancer.
During admission, 82-year-old Mr. Robeson is brought to the medical-surgical unit for diagnostic confirmation and management of probable delirium. Which statement by the client's daughter best supports the diagnosis?
- A. "Maybe it's just caused by aging. This usually happens by age 82."
- B. "The changes in his behavior came on so quickly! I wasn't sure what was happening."
- C. "Dad just didn't seem to know what he was doing. He would forget what he had for breakfast."
- D. "Dad has always been so independent. He's lived alone for years since mom died."
Correct Answer: B
Rationale: The correct answer is B because sudden onset of behavioral changes is a typical symptom of delirium. Delirium is characterized by an acute and fluctuating disturbance in attention, awareness, and cognition. Choice A is incorrect because delirium is not a normal part of aging. Choice C describes memory issues, which can be seen in delirium but are less specific than sudden behavioral changes. Choice D, while it mentions the patient's independence, does not directly support the diagnosis of delirium.
Abrupt withdrawal or discontinuation of prednisone can cause:
- A. adrenal crisis.
- B. hypercortisolism.
- C. ACTH stimulation.
- D. thyroid crisis.
Correct Answer: A
Rationale: The correct answer is A: adrenal crisis. Abrupt discontinuation of prednisone can lead to adrenal insufficiency, resulting in adrenal crisis. Prednisone is a corticosteroid that suppresses the adrenal glands' ability to produce cortisol. Abrupt withdrawal can cause a sudden drop in cortisol levels, leading to adrenal crisis with symptoms like fatigue, weakness, abdominal pain, and potentially life-threatening low blood pressure. Choices B, C, and D are incorrect because hypercortisolism refers to excess cortisol levels, ACTH stimulation would not result from prednisone withdrawal, and thyroid crisis is not directly related to corticosteroid discontinuation.
During the home visit of a client with dementia, the nurse notes that an adult daughter persistently corrects her father's misperceptions of reality, even when the father becomes upset and anxious. Which intervention should the nurse teach the caregiver?
- A. Anxiety-reducing measures
- B. Positive reinforcement
- C. Reality orientation techniques
- D. Validation techniques
Correct Answer: D
Rationale: The correct answer is D: Validation techniques. In dementia care, using validation techniques involves acknowledging the person's feelings and reality, even if it differs from actual events or facts. It helps in reducing the client's anxiety and distress. In this scenario, the daughter persistently correcting her father's misperceptions can escalate his anxiety. Teaching the daughter validation techniques will encourage her to validate her father's feelings and perceptions, ultimately promoting a more supportive and less confrontational environment. Choices A, B, and C are incorrect in this context. While anxiety-reducing measures can be beneficial, the primary issue here is the father's misperceptions being consistently corrected. Positive reinforcement focuses on rewarding desired behaviors, which is not directly related to the situation described. Reality orientation techniques involve constantly reminding the person of the correct time, place, and other details, which may not be suitable for someone with dementia experiencing distress.
During a home visit to a family of three: a mother, father, and their child, the mother tells the community nurse that the father (who is not present) had hit the child on several occasions when he was drinking. The mother further explains that she has talked her husband into going to Alcoholics Anonymous and asks the nurse not to interfere so her husband won't get angry and refuse treatment. Which of the following is the best response of the nurse?
- A. The nurse agrees not to interfere if the husband attends an Alcoholics Anonymous meeting that evening.
- B. The nurse commends the mother's efforts and agrees to let her handle things.
- C. The nurse commends the mother's efforts and also contacts protective services.
- D. The nurse confronts the mother's failure to protect the child.
Correct Answer: C
Rationale: In this situation, the best response for the nurse is to commend the mother's efforts in seeking help for her husband by encouraging him to attend Alcoholics Anonymous. However, it is crucial for the nurse to also contact protective services to ensure the safety and well-being of the child. Option A is incorrect as it is not appropriate to condition non-interference on the husband attending a meeting that evening. Option B is incorrect because solely letting the mother handle things might put the child at risk. Option D is incorrect as it does not address the immediate need to ensure the child's safety through involving protective services.