A client on an inpatient unit angrily says to a nurse. "Peter is not cleaning up after himself in the community bathroom. You need to address this problem. Which is the appropriate nursing response?

I'll talk to Peter and present your concerns."

I can see that you are angry. Let's discuss ways to approach Peter with your concerns."

Why are you overeacting to the issue

You should bring this to the attention of your treatment team.

Answer and Explanation

The Correct Answer is A

A. "I can see that you are angry. Let's discuss ways to approach Peter with your concerns."

This response is empathetic and invites the client to discuss their concerns. However, it doesn't explicitly address the client's request for the nurse to take action. The more appropriate approach would involve the nurse taking direct responsibility for addressing the issue.

B. "Why are you overreacting to the issue?"

This response may be perceived as dismissive and judgmental. It does not validate the client's concerns or address the issue constructively.

C. "You should bring this to the attention of your treatment team."

While involving the treatment team is important, the client has directly approached the nurse with a concern. It is appropriate for the nurse to take the initial step in addressing the issue directly rather than immediately redirecting the client to the treatment team.

D. "I'll talk to Peter and present your concerns."

This is the most appropriate response. It acknowledges the client's concerns, takes responsibility for addressing the issue, and ensures that the client's voice is heard. The nurse can discuss the matter with Peter and work towards a resolution.

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Correct Answer is B

Explanation

A. fluoxetine (Prozac):

Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) commonly used to treat depression and anxiety disorders. While SSRIs can have side effects, significant alterations in cardiac or cerebral electrical conductivity and fluid/electrolyte imbalance are not typically associated with fluoxetine. The primary concerns with SSRIs are related to serotonin levels and can include gastrointestinal disturbances, insomnia, and sexual dysfunction.

B. Lithium (Lithobid):

This is the correct answer. Lithium is known to have potential side effects related to cardiac and cerebral function, as well as fluid and electrolyte balance. Monitoring blood levels of lithium is crucial to avoid toxicity, which can affect the cardiovascular and central nervous systems. Lithium toxicity can lead to symptoms such as tremors, confusion, ataxia, and, in severe cases, seizures.

C. venlafaxine (Effexor):

Venlafaxine is a serotonin-norepinephrine reuptake inhibitor (SNRI) commonly used to treat depression and anxiety disorders. While it can cause some cardiovascular effects, the concern for significant alterations in cardiac or cerebral electrical conductivity and fluid/electrolyte imbalance is generally lower compared to lithium. The primary side effects of venlafaxine are related to serotonin and norepinephrine levels and may include increased blood pressure and heart rate.

D. clozapine (Clozaril):

Clozapine is an atypical antipsychotic medication used to treat schizophrenia. While antipsychotics can have side effects related to metabolic changes, significant alterations in cardiac or electrolyte imbalances are not typically associated with clozapine as the primary concern. Regular monitoring for metabolic side effects, such as weight gain and changes in lipid and glucose levels, is important with antipsychotic medications.

A. Limit time for the client to perform activities B. Rotate assignment of daily caregivers. C. Provide an activity schedule that changes from day to day. D. Talk the client through tasks one step at a time

Correct Answer is D

Explanation

A. Limit time for the client to perform activities:

This option may increase agitation and frustration for the client with Alzheimer's disease. It is generally not recommended to limit their time for activities, as it may lead to distress.

B. Rotate assignment of daily caregivers:

Consistency in caregivers is often beneficial for individuals with Alzheimer's disease. Constantly changing caregivers can lead to confusion and anxiety for the client. Thus, rotating caregivers is not the best approach.

C. Provide an activity schedule that changes from day to day:

Individuals with Alzheimer's disease often benefit from routine and predictability. Changing the activity schedule daily can cause confusion and disorientation. Therefore, it is not the most appropriate intervention.

D. Talk the client through tasks one step at a time:

This is the best choice because breaking down tasks into simple, manageable steps can help individuals with Alzheimer's disease understand and follow instructions. It promotes a sense of accomplishment and reduces frustration. This approach is aligned with the principles of dementia care.

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A client on an inpatient unit angrily says to a nurse. "Peter is not cleaning up after himself in the community bathroom. You need to address this problem. Which is the appropriate nursing response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse cares for four patients who are receiving clozapine, lithium, fluoxetine, and venlafaxine, respectively. For which patient should the nurse be most alert for alterations in cardiac or cerebral electrical conductivity as well as fluid and electrolyte imbalance? The patient receiving:

Correct Answer is B

Explanation

A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

Correct Answer is D

Explanation

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