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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Avoid stimulation of the breasts and wear a tight bra: This is the most appropriate recommendation for a bottle-feeding postpartum client with breast engorgement. Minimizing breast stimulation and wearing a supportive, tight-fitting bra can help reduce milk production and alleviate discomfort.

B. Express a small amount of breast milk by hand: This action may provide temporary relief but can stimulate further milk production, which is not advisable for a client who is bottle-feeding and attempting to suppress lactation.

C. Place warm packs on both breasts: Warmth can promote milk flow and is typically recommended for breastfeeding mothers. For a bottle-feeding client, cold compresses are more appropriate to reduce engorgement.

D. Take a prescribed analgesic and expose breasts to air: While analgesics can help manage discomfort, exposing the breasts to air has no therapeutic benefit for engorgement and may increase discomfort. This is not the best overall recommendation.

A. Leave the client's room so she can act out her anxiety. B. State it is unacceptable to undress during the interview. C. Ignore the client's inappropriate behavior. D. Change to less anxiety-provoking questions.

Correct Answer is B

Explanation

A: Leaving the client alone could increase the risk of harm to herself or others and does not address the immediate need for safety and boundaries.
B: Clearly stating that undressing is unacceptable sets immediate boundaries, which is essential in managing acute behavioral situations, ensuring the client's dignity, and maintaining a professional environment.
C: Ignoring the behavior does not provide any guidance or boundaries for the client, which could lead to escalation or reinforce the inappropriate behavior.
D: While changing to less anxiety-provoking questions may be helpful, it does not directly address the behavior at hand, which could lead to further inappropriate actions or misunderstandings about acceptable behavior during the assessment.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A postpartum client who is bottle-feeding develops breast engorgement. Which is the best recommendation for the nurse to provide this client?

Correct Answer is A

Explanation

While the nurse is conducting an admission assessment of a female client with bipolar disorder, the client suddenly begins to take off her clothes and throw them about the room. Which action should the nurse take first?

Correct Answer is B

Explanation

A client admitted to the hospital with a suspected ruptured diverticulum develops signs and symptoms of septic shock. The healthcare provider prescribes a sepsis protocol. Which intervention is most important for the nurse to include in the plan of care?

A client with pancreatic cancer develops ascites, and 2 liters of fluid are removed via paracentesis. Which schedule should the nurse implement to assess the client's blood pressure after this procedure?

The nurse observes a client with amyotrophic lateral sclerosis (ALS) is excessively drooling and prepares to suction the client's oral cavity. Which action should the nurse include?

The nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. Which information is most important for the nurse to include?

A client with chronic obstructive pulmonary disease (COPD) receives a prescription for chest physiotherapy (CPT) to help mobilize secretions. Following the therapy, which finding indicates to the nurse that the intervention was effective?

Exhibits The nurse inspects the airway. There is no visible trauma, and the airway appears to be patent. What other assessment items are included in the primary survey? Select all that apply.

The nurse observes an unlicensed assistive personnel (UAP) who is preparing to provide personal care for a client who requires contact precautions. The UAP has applied a gown and gloves and secured the tops of the gloves over the gown sleeves. Which action should the nurse take?

Exhibits The nurse would determine what actions to implement in an emergent situation. Drag from Word Choices to complete the sentence. The client is at immediate risk for developing dropdown-1,dropdown-2 and dropdown-3