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The 80-year-old male client on an Alzheimer’s unit is agitated and asking the nurse to get his father to come and see tenor him. Which is the nurse’s best response?
- A. Tell the client his father is dead and cannot come to see him.
- B. Give the client the phone and have him attempt to call his father.
- C. Ask the client to talk about his father with the nurse.
- D. Call the family so they can tell the client why his father cannot come to see him.
Correct Answer: C
Rationale: In Alzheimer’s, agitation and confusion require validation. Talking about his father (C) redirects and calms the client. Stating death (A) may distress, calling (B) reinforces delusion, and involving family (D) is unnecessary.
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The client is diagnosed with Wernicke-Korsakoff syndrome as a result of chronic alcoholism. For which symptoms would the nurse assess?
- A. Insomnia and anxiety.
- B. Visual or auditory hallucinations.
- C. Extreme tremors and agitation.
- D. Ataxia and confabulation.
Correct Answer: D
Rationale: Wernicke-Korsakoff syndrome, due to thiamine deficiency in alcoholism, causes ataxia (unsteady gait) and confabulation (fabricated memories, D). Insomnia/anxiety (A), hallucinations (B), and tremors/agitation (C) are less specific.
The son of a client diagnosed with ALS asks the nurse, 'Is there any chance that I could get this disease?' Which statement by the nurse would be most appropriate?
- A. It must be scary to think you might get this disease.'
- B. No, this disease is not genetic or contagious.'
- C. ALS does have a genetic factor and runs in families.'
- D. If you are exposed to the same virus, you may get the disease.'
Correct Answer: C
Rationale: About 5–10% of ALS cases are familial, with a genetic component (C). Reflecting fear (A) is vague, denying genetics (B) is incorrect, and viral causes (D) are not established.
Which teaching topics should the nurse cover before discharge? Select all that apply.
- A. Dietary restrictions
- B. Avoiding heavy lifting
- C. Staying out of bright sunlight
- D. Missed doses
- E. Bruising or blood in urine
- F. Need for frequent laboratory work
Correct Answer: A,D,E,F
Rationale: Warfarin requires dietary consistency, instructions on missed doses, monitoring for bleeding (bruising/blood in urine), and frequent INR checks.
The nurse has written a care plan for a client diagnosed with a brain tumor. Which is an important goal regarding self-care deficit?
- A. The client will maintain body weight within two (2) pounds.
- B. The client will execute an advance directive.
- C. The client will be able to perform three (3) ADLs with assistance.
- D. The client will verbalize feeling of loss by the end of the shift.
Correct Answer: C
Rationale: A realistic goal for self-care deficit is performing ADLs with assistance (C), addressing functional limitations due to the tumor. Weight maintenance (A), advance directives (B), and verbalizing loss (D) are not directly related to self-care.
The public health nurse is giving a lecture on potential outbreaks of infectious meningitis. Which population is most at risk for an outbreak?
- A. Clients recently discharged from the hospital.
- B. Residents of a college dormitory.
- C. Individuals who visit a third world country.
- D. Employees in a high-rise office building.
Correct Answer: B
Rationale: College dormitory residents (B) are at high risk for meningococcal meningitis due to close living conditions and shared spaces. Hospital discharges (A), travel (C), or office workers (D) are less specific risks.