A client diagnosed with Alzheimer's Disorder has impairments of memory and judgement and is incapable of performing activities of daily living. Which nursing intervention should take priority?

Assist the client with bathing and toileting.

Design a bulletin board to represent the current season.

Present evidence of objective reality to improve cognition.

Label the door to the client's room with name and number.

Answer and Explanation

The Correct Answer is A

a. Assist the client with bathing and toileting. This intervention addresses the client's immediate and essential needs. Ensuring basic hygiene and toileting are crucial for maintaining the client's health, dignity, and comfort. Assisting with activities of daily living (ADLs) is a priority for clients who are unable to perform these tasks independently.
b. Design a bulletin board to represent the current season. While this can help with orientation and provide a sense of time and place, it is not as critical as addressing the client's basic physical needs.
c. Present evidence of objective reality to improve cognition. Reality orientation can be beneficial, but it is not a priority intervention compared to meeting the client's immediate physical needs.
d. Label the door to the client's room with name and number. This helps with orientation and independence but is less critical than ensuring the client’s hygiene and toileting needs are met.

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Correct Answer is ["B","C","D"]

Explanation

a. time of day. The time of day is not a significant factor in determining whether a situation will be perceived as a crisis.
b. client's perception of the event. This is correct because an individual's perception of an event greatly influences whether it is experienced as a crisis.
c. availability of adequate coping mechanisms. This is correct because having effective coping mechanisms can mitigate the impact of a stressful situation and prevent it from becoming a crisis.
d. availability of supports. This is correct because having a supportive network can help individuals manage stress and reduce the likelihood of a crisis.
e. location of a treatment centre. While access to treatment is important, the immediate experience of a crisis is more influenced by perception, coping mechanisms, and support systems than the location of a treatment centre.

A. "I can make that promise to you based on nurse-client privilege." B. "Those kinds of thoughts will make your hospitalization longer." C. "I cannot promise that. Confidentiality does not include plans to hurt others." D. "You should share this thought with your psychiatrist."

Correct Answer is C

Explanation

a. "I can make that promise to you based on nurse-client privilege." Nurse-client confidentiality is important, but it doesn't apply to threats of violence. The nurse has a duty to protect the client and others.
b. "Those kinds of thoughts will make your hospitalization longer." While true, this response doesn't directly address the safety concern and might be perceived as judgmental.
c. "I cannot promise that. Confidentiality does not include plans to hurt others." This is a clear and honest statement. It explains the limitations of confidentiality and prioritizes safety.
d. "You should share this thought with your psychiatrist." While encouraging the client to talk to a psychiatrist is a good suggestion, it doesn't directly address the confidentiality issue or the immediate threat.

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A client diagnosed with Alzheimer's Disorder has impairments of memory and judgement and is incapable of performing activities of daily living. Which nursing intervention should take priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse understands that whether or not a client experiences crisis as a result of a stressful situation depends on the: (SELECT ALL THAT APPLY)

Correct Answer is ["B","C","D"]

Explanation

A client asks the nurse to promise to keep confidential a plan the client has to kill their father. Which of the following statements would be the best response for the nurse to make?

Correct Answer is C

Explanation

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