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

Rationale for A: Redressing the abdominal incision is crucial as the dressing is no longer occlusive, which could lead to infection. An intact dressing also prevents the client from picking at the site, which could cause further harm or delay healing.
Rationale for B: Leaving the lights on might help with visual perception for a client with dementia, but it does not directly address the immediate risk of infection or the client's interference with the dressing.
Rationale for C: Applying restraints could be considered for a client who is at risk of harming themselves, but this should be a last resort after other interventions have been tried due to the potential for physical and psychological harm.
Rationale for D: Replacing the IV site with a smaller gauge is not indicated by the pink insertion site alone and does not address the client's confusion or behavior towards the dressing.

A. Currently prescribed medications. B. Falling from a ladder as reason for admission. C. Increasing confusion of the client. D. Client's healthcare power of attorney.

Correct Answer is C

Explanation

A. Currently prescribed medications are important information, but in this emergent situation, the nurse should first report on the client's condition and immediate concerns.

B. Falling from a ladder as the reason for admission is relevant information, but it does not address the immediate clinical concern of the client's altered mental status.

C. Reporting the increasing confusion of the client is the priority as it highlights the acute change in neurological status, which may indicate a more critical issue such as intracranial injury or neurological impairment.

D. The client's healthcare power of attorney is important for long-term care planning, but it is not the immediate concern when the client presents with altered mental status and potential head
trauma.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Correct Answer is C

Explanation

The nurse is monitoring a client with Cushing's disease in the postanesthesia care unit (PACU) after a hypophysectomy. Which intervention is most important for the nurse to include in the client's plan of care?

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 who is hypotensive is receiving dopamine, an adrenergic agonist, intravenously (IV) at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

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.

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

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?