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The nurse is observing the interaction between a parent and child with schizophrenia. The child states, 'The man visiting me said you went on vacation without me.' The parent replies 'There is no man, you are just making that up.' When interacting with the parent privately, which reply from the parent would the nurse suggest?
- A. I am not on vacation. I am here with you.
- B. How can I go on vacation. I do not have any money.
- C. Stop saying that. You know better. No one told you that.
- D. Just forget about that and let's talk about something else.
Correct Answer: A
Rationale: The nurse is correct to suggest not arguing with the client. This can escalate the situation. The nurse should suggest not validating the delusional belief and focus the discussion to the 'here and now.'
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The nurse is instructing the parents of a 21-year-old with schizophrenia who hears voices. Which response by the parent to the child validates that the parent understands the discharge teaching?
- A. The parent states 'Does the person speaking have a name?'
- B. The parent states 'The person speaking to you is bad, but you are good.'
- C. The parent states 'The voice is not real. We have talked about this before.'
- D. The parent states 'I do not hear the voices, but what are they telling you?'
Correct Answer: D
Rationale: The parent is most correct to state not hearing the voices but then asking the client to share what the voices are saying. By identifying the content of the hallucinations, the parent can determine the safety of the client or if others are in jeopardy. Also, the parent is correct to call the auditory hallucinations by the term 'the voices.'
The nurse is caring for a client who is concerned about having the beginning symptoms of Alzheimer disease. Which question is helpful in determining risk factors?
- A. Has your house been tested for high radon levels?
- B. Do you have any family with Alzheimer disease?
- C. How many times a week do you eat red meat?
- D. At which time of day do you experience most symptoms?
Correct Answer: B
Rationale: The nurse asks the client about the family health history. The nurse is correct to understand that if the client has a first-degree relative with Alzheimer's disease, the client's risk for the disease doubles. The other options are not helpful in determining risk factors.
Which of the following is an outcome of the drug memantine (Namenda) in clients with advanced stages of Alzheimer disease?
- A. Less depression
- B. Increased brain excitability
- C. Lessens symptoms
- D. Decreased brain excitability
Correct Answer: C
Rationale: Clients in advanced stages of Alzheimer disease have fewer symptoms when taking memantine than others who were given a placebo.
Which of the following nursing diagnoses would be of highest priority for a client diagnosed with advanced Alzheimer disease?
- A. Chronic Confusion
- B. Memory Impairment
- C. Impaired Verbal Communication
- D. Aspiration Risk
Correct Answer: D
Rationale: When identifying a priority, select the diagnosis that could be the most harmful. The nurse is most correct to select Aspiration Risk as the highest priority. Aspiration can potentially cause pneumonia. Memory Impairment and Chronic Confusion are manageable with appropriate supervision. Impaired Verbal Communication is an obstacle in expressing thoughts and feelings.
Which family-centered nursing diagnosis is a priority for Alzheimer disease clients who have a spouse providing care?
- A. Altered Health Maintenance
- B. Fatigue
- C. Caregiver Fatigue
- D. Grief
Correct Answer: C
Rationale: A priority family-centered nursing diagnosis related to a spouse who is providing care is Caregiver Fatigue. The nurse determines family-specific interventions that can assist the spouse or family in care for themselves while caring for the client. Altered Health Maintenance is a client diagnosis. Fatigue and Grief are also potential diagnoses but not as high a priority as Caregiver Fatigue.