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Which technique is most therapeutic for helping clients with dementia remain oriented?
- A. Address all clients using their first name.
- B. Ask clients to identify their goals for the day.
- C. Assign clients to greet visitors each day.
- D. Post large calendars with the current date.
Correct Answer: D
Rationale: Large calendars provide a constant visual cue, aiding orientation to time in clients with dementia.
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The client who sustained a brain injury from an MVA is now experiencing aggression impulsivity and poor judgment. In teaching the family which area of the brain illustrated should the nurse identify as being affected?
- A. Line A
- B. Line B
- C. Line C
- D. Line D
Correct Answer: B
Rationale: The prefrontal cortex (Line B) modulates judgment aggression and impulsivity. Cortex (A) controls motor functions hypothalamus (C) regulates temperature/fluids and cerebellum (D) manages balance. image4.png
When the client begins crying and says, 'Nurse, I feel like I'm going to die,' which response is most therapeutic?
- A. You are having a panic attack.
- B. You don't want the physician to see you this way.
- C. Everyone feels frightened in an emergency.
- D. I'll stay with you until you feel better.
Correct Answer: D
Rationale: Staying with the client provides reassurance and support, directly addressing their fear and promoting a sense of security.
The nurse is counseling the client with a substance abuse disorder. Which defense mechanism is the nurse most likely to observe the client using in response to a stressful event?
- A. Repression
- B. Regression
- C. Sublimation
- D. Reaction formation
Correct Answer: B
Rationale: Regression (B) is common in substance abuse showing childlike behaviors. Repression (A) sublimation (C) and reaction formation (D) are less typical.
Which approach is best for managing the client's care?
- A. Use a nonjudgmental manner when cleaning the client of stool.
- B. Ask the client's spouse to perform hygiene measures.
- C. Hold the client responsible for all hygiene.
- D. Assign same-gender nurses to care for the client.
Correct Answer: A
Rationale: A nonjudgmental approach preserves the client's dignity, reducing embarrassment and supporting self-esteem during hygiene care.
The nurse assesses the client every 15 minutes. What objective evidence will the nurse detect that indicates that the restraints are too tight? Select all that apply.
- A. The client reports being unable to move the right hand.
- B. The client's fingers and toes are pale.
- C. The client reports having pain.
- D. Capillary refill is greater than 6 seconds.
- E. There is excoriation around the wrist.
- F. The client reports numbness and tingling.
Correct Answer: B,D,F
Rationale: Pallor, prolonged capillary refill, and numbness indicate impaired circulation, suggesting restraints are too tight and compromising blood flow.