Nokea
The spouse of a client with Alzheimer's disease expresses concern about the burden of caregiving. Which of the following actions by the nurse should be a priority?
- A. Link the caregiver with a support group
- B. Ask friends to visit regularly
- C. Schedule a home visit each week
- D. Request anti-anxiety prescriptions
Correct Answer: A
Rationale: Assisting caregivers to locate and join support groups is most helpful. Families share feelings and learn about services such as respite care. Health education is also available through local and national Alzheimer's chapters.
You may also like to solve these questions
A nurse is reinforcing teaching to a client that breastfeeds who has been diagnosed with mastitis of the right breast. Which of the following instructions should be included? Select all that apply.
- A. Cease breastfeeding from right breast
- B. Increase oral fluid intake
- C. Reduce frequency of feeds to every 8 hours in right breast
- D. Take ibuprofen as needed for pain
- E. Use a tight-fitting underwire bra 24 hours per day
Correct Answer: B, D
Rationale: Increased fluids (B) and ibuprofen (D) manage dehydration and pain. Ceasing breastfeeding (A) or reducing feeds (C) can worsen mastitis, and tight bras (E) may increase discomfort.
The nurse is assisting with care of a client with blunt head injury admitted for observation, including hourly neurologic checks. At 1:00 AM, the client reports a headache; the neurologic check is normal, and the nurse administers acetaminophen prn. At 2:00 AM, the client appears to be sleeping. What action does the nurse anticipate taking?
- A. Arouse the client and ask what the current month is
- B. Awaken the client and check for paresthesia
- C. Document 'relief apparently obtained' and recheck at 3:00 AM
- D. Let the client sleep but verify respiratory rate
Correct Answer: A
Rationale: Hourly neurologic checks require arousing the client to assess orientation (A). Checking paresthesia (B), assuming relief (C), or only verifying respiratory rate (D) do not meet monitoring requirements.
The nurse is beginning nutritional counseling/teaching with a pregnant woman. What is the initial step in this interaction?
- A. Teach her how to meet the needs of self and her family
- B. Explain the changes in diet necessary for pregnant women
- C. Question her understanding and use of the food pyramid
- D. Conduct a diet history to determine her normal eating routines
Correct Answer: D
Rationale: Assessment is always the first step in planning teaching for any client. A thorough and accurate history is essential for gathering the needed information.
A client has chronic obstructive pulmonary disease exacerbation. The pulse oximeter shows a saturation of 86% on room air. The nurse finds bilateral diminished lung sounds and low-pitched wheezing posteriorly, shallow respirations, respiratory rate of 32/min, and use of accessory muscles. What is the most appropriate oxygen delivery device for this client?
- A. Nasal cannula
- B. Non-rebreathing mask
- C. Oxymizer
- D. Venturi mask
Correct Answer: D
Rationale: A Venturi mask (D) delivers precise oxygen concentrations, ideal for COPD exacerbation to avoid hypercapnia. Nasal cannula (A), non-rebreathing mask (B), and Oxymizer (C) are less precise.
The nurse assigns an unlicensed assistive personnel (UAP) to care for a client with a musculoskeletal disorder. The client ambulates with a leg splint. Which task requires supervision of the UAP?
- A. Report signs of redness overlying a joint
- B. Monitor the client's response to ambulatory activity
- C. Encouragement for the independence in self-care
- D. Assist the client to transfer from a bed to a chair
Correct Answer: B
Rationale: Monitor the client's response to interventions requires assessment, a task to be performed by an RN.