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When the older client with Alzheimer's disease is confused about how to use a fork, which nursing action is best for prolonging an ability to maintain self-care?
- A. Ask the physician to order a liquid diet.
- B. Position the client to promote mimicking other clients.
- C. See the client first so there is sufficient time to eat.
- D. Seat the client alone so no one will see any mess that occurs.
Correct Answer: B
Rationale: Mimicking others leverages social cues, encouraging independent eating and prolonging self-care abilities.
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Which action is best to use initially when trying to help the angry client maintain self-control?
- A. Administer a sedative.
- B. Apply four-point restraints.
- C. Use a calm voice and approach.
- D. Place the client in seclusion.
Correct Answer: C
Rationale: A calm voice and approach de-escalates anger by creating a non-threatening environment, encouraging the client to regain control.
What is the best approach for reorienting a confused client who wanders into other clients' rooms?
- A. Place a large sign with the client's name on the door.
- B. Keep the room doors on the unit locked at all times.
- C. Restrain the client in a wheelchair when unattended.
- D. Speak to the client about invading other people's privacy.
Correct Answer: C
Rationale: Restraining in a wheelchair prevents wandering while respecting dignity, though it must be used cautiously and per protocol.
Staff members have expressed fear of the client who has a history of violent behavior. Which response made by the lead nurse would be most beneficial in addressing the staff’s expressed concerns?
- A. “Let’s not prejudge him. His medication should help him control his behavior.”
- B. “I will be very attentive to his behavior monitoring it for any signs of escalation.”
- C. “It may be hard but we need to appear calm and nonthreatening but alert to his behavior.”
- D. “As staff we are all trained to manage violent clients and we can handle any crisis behavior.”
Correct Answer: C
Rationale: Appearing calm and nonthreatening (C) addresses staff concerns and guides management. Prejudging (A) personal monitoring (B) or overconfidence (D) dismiss staff fears.
The nurse is preparing to administer thiamine (vitamin B1) to the client receiving treatment for alcohol dependence. Which statement best describes the rationale for the use of thiamine?
- A. Thiamine improves the absorption of other essential vitamins and folic acid.
- B. Thiamine helps to reverse the malnutrition often associated with alcohol abuse.
- C. Thiamine reduces the risk of seizures occurring during withdrawal from alcohol.
- D. Thiamine prevents neuropathy and confusion associated with chronic alcohol use.
Correct Answer: D
Rationale: Thiamine prevents neuropathy and confusion from deficiency (D). It doesn’t aid absorption (A) malnutrition reversal (B) is secondary and seizures (C) need anticonvulsants.
While reviewing the client's psychiatric history, the nurse would expect to note which major characteristic of bipolar disorder?
- A. Ritualistic behavior
- B. Symbolic aggressiveness
- C. Cyclic mood swings
- D. Periodic amnesia
Correct Answer: C
Rationale: Cyclic mood swings, alternating between mania and depression, are the hallmark of bipolar disorder, defining its clinical presentation.