A client with end-stage Alzheimer's disease is brought to the clinic by the caregiver for an appointment with the healthcare provider. The caregiver speaks privately to the nurse about not sleeping well at night and experiencing frequent periods of crying. Which intervention should the nurse implement?

Suggest social services be contacted to find a respite care facility for the client.

Propose the extended family could return to the area to help provide assistance.

Tell the caregiver to consider hiring a private duty nurse for time to be away.

Advise to have a case management evaluation of the client's home environment.

Answer and Explanation

The Correct Answer is A

A. Suggest social services be contacted to find a respite care facility for the client.
This is the correct answer. Respite care provides temporary relief for primary caregivers, offering them a break from the daily routine and stress of caregiving. This can be crucial in preventing caregiver burnout and addressing the caregiver's emotional and physical health needs.

B. Propose the extended family could return to the area to help provide assistance.
While involving extended family might be helpful, it is not always feasible or the most immediate solution. The caregiver needs structured, reliable support, which can be effectively provided through respite care services.

C. Tell the caregiver to consider hiring a private duty nurse for time to be away.
Hiring a private duty nurse can be expensive and might not be a viable option for all families. While it could be beneficial, it may not be the best initial suggestion given the caregiver's current stress and emotional state.

D. Advise to have a case management evaluation of the client's home environment.
While a case management evaluation might help in assessing and improving the home environment and care plan, it does not directly address the immediate need for relief and support for the caregiver's emotional and physical well-being.

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

Semi Fowler's position:

- This position involves raising the head of the bed to an angle of 30 to 45 degrees. It is

commonly used to improve respiratory function and comfort in patients who are experiencing

difficulty breathing. By elevating the head and torso, this position facilitates better lung expansion, helping to improve oxygenation.

Promote lung expansion:

- In patients with respiratory issues such as pneumonia, positioning that enhances lung expansion is critical. Semi Fowler's position helps to reduce pressure on the diaphragm, allowing for more effective lung expansion and improved oxygenation. This is particularly important for a patient with decreased breath sounds and consolidation in the lungs, as it aids in alleviating respiratory distress and improving gas exchange.

A. "How do you cope with the voices?" B. "When do you hear voices?" C. "Which medication works best?" D. "What are the voices saying?"

Correct Answer is D

Explanation

A. "How do you cope with the voices?" is an important question to assess the client's coping mechanisms, but it does not provide direct information about the content or nature of the auditory hallucinations. While coping strategies are relevant, understanding the nature of the hallucinations is crucial for treatment planning.

B. "When do you hear voices?" is important to understand the timing and frequency of the hallucinations, but it does not provide information about the content or nature of the hallucinations themselves.

C. "Which medication works best?" is important to assess the client's previous treatment history and response to medication, but it does not directly address the current assessment of the auditory hallucinations.

D. "What are the voices saying?" is the most important question because it directly addresses the content and nature of the auditory hallucinations. Understanding the specific content, tone, and perceived significance of the voices can provide valuable information for diagnosis, treatment planning, and assessing the client's level of distress or impairment.

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Naxlex Comprehensive Predictor Exams

Exhibits The nurse should place the client in a position to promote

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

A client with schizophrenia reports auditory hallucinations when admitted to the hospital. Which question is most important for the nurse to include in the assessment of this client?

Correct Answer is D

Explanation

The nurse is providing discharge instructions to a client with gout in the left great toe who received a prescription for prednisone 30 mg by mouth to be administered each day. Which symptom should the nurse explain is most important for the client to report to the healthcare provider?

After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to the practical nurse (PN)?

The nurse is caring for a client with heart failure. Which of these prescribed medications places the client at risk for cardiogenic shock?

The nurse who is working in the emergency department is obtaining evidence for a rape kit from a woman who reports that she was raped while returning to her dormitory from the university library. Which intervention is most important for the nurse to implement?

A client with a right hemopneumothorax has a chest tube connected to suction. While turning to the left side, the client becomes suddenly short of breath and anxious. Which intervention should the nurse implement?

Exhibits Which may have caused the change in the Glasgow Coma Scale score between 2000 and 2400? Select all that apply.

Exhibits Following the fluid bolus, the client is more awake and able to answer questions. What questions are appropriate for the secondary survey? Select all that apply.