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 D

Explanation

A. This action pertains more to discussions about advance care planning and end-of-life preferences, which may be important but are not directly related to assessing the client's functional status.

B. Episodes of sundowning are associated with changes in behavior, confusion, and agitation in some individuals with dementia, particularly in the late afternoon or evening. While important to assess in certain contexts, it is not directly related to evaluating the client's physical strength and mobility.

C. Asking the client to lie still does not provide information about their functional status or ability to perform activities of daily living.

D. This is the most appropriate action because it directly addresses the client's reported decreased strength and assesses the impact on their functional ability. Falls are a common consequence of reduced strength and mobility in older adults and can provide valuable information about the client's current physical function and safety.

A. Instruct the family about withdrawal symptoms. B. Initiate seizure precautions. C. Obtain a serum drug screen. D. Administer naloxone per PRN protocol.

Correct Answer is B

Explanation

A. Instruct the family about withdrawal symptoms. While educating the family about withdrawal symptoms is important for support and understanding, it is not the best initial action when the
client is experiencing severe agitation and tremors. Safety measures should be prioritized.

B. Initiate seizure precautions. Severe agitation and tremors can be signs of benzodiazepine withdrawal, which may progress to seizures. Initiating seizure precautions, such as ensuring a
safe environment, padding side rails, and having emergency medications and equipment readily available, is the priority to prevent injury.
C. Obtain a serum drug screen. While obtaining a serum drug screen may be necessary to confirm benzodiazepine withdrawal, it is not the immediate action needed to address the client's current symptoms and prevent potential harm.
D. Administer naloxone per PRN protocol. Naloxone is an opioid antagonist used to reverse opioid overdose and is not indicated for benzodiazepine withdrawal. Administering naloxone would not be appropriate or effective in this situation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client arrives at the clinic reporting decreased strength in knees and in handgrips. Which action should the nurse include in a functional assessment of the client?

Correct Answer is D

Explanation

A client experiencing withdrawal from the benzodiazepine alprazolam is demonstrating severe agitation and tremors. Which is the best initial nursing action?

Correct Answer is B

Explanation

The nurse identifies an electrolyte imbalance, an elevated blood pressure, and a weight gain of 4.4 lbs (2 kg) in 24 hours for a client with hepatic failure. Which intervention should the nurse include in the plan of care?

Exhibits What laboratory specimens would the nurse expect for the provider to order? Select all that apply.

The nurse is preparing a dose of 60 mcg of teriparatide. The medication is labeled "750 mcg/2.4 mL". How many ml. should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

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