A home health nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain?

The partner has placed locks at the top of the doors leading to the outside.

The partner redirects the client when the client is frustrated.

The partner has hired a house cleaner.

The partner has lost 25 lbs in the past 3 months.

Answer and Explanation

The Correct Answer is D

The correct answer is choice D: "The partner has lost 25 lbs in the past 3 months."

Choice D rationale:

This choice is the correct answer because significant weight loss in a caregiver, such as the partner of a client with Alzheimer's disease, is indicative of caregiver role strain. Caregiver role strain refers to the physical, emotional, and psychological stress experienced by caregivers due to the demands of providing care for a loved one. Weight loss in this context suggests that the partner's own health and well-being are being compromised due to the caregiving responsibilities.

Choice A rationale:

This choice might be related to safety concerns and trying to prevent the client from wandering, but it does not directly indicate caregiver role strain. Placing locks at the top of doors is a common safety measure to prevent clients with Alzheimer's disease from wandering and getting lost.

Choice B rationale:

This choice is actually a positive observation. Redirecting a frustrated client is a helpful and appropriate caregiving strategy. It indicates that the partner is actively engaged in managing the client's behavior and emotions, which is not a sign of caregiver role strain.

Choice C rationale:

Hiring a house cleaner is a practical decision and could be a sign of the partner's effort to manage their caregiving responsibilities more effectively. While it might imply a certain level of stress, it doesn't directly point to caregiver role strain as much as the significant weight loss does.

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Correct Answer is D

Explanation

Choice D rationale:

Setting limits on the client's behavior and maintaining consistency is essential when dealing with a client experiencing a manic episode. Manic episodes are characterized by impulsive and often disruptive behaviors. By setting clear limits, the nurse establishes boundaries that help manage the disruptive behavior and maintain a safe and therapeutic environment. Consistency in approach is vital to avoid confusion and to provide the client with a sense of stability during a time when their judgment and impulse control might be impaired.

Choice A rationale:

Warning the client that further disruptions will result in seclusion might escalate the situation and potentially worsen the client's agitation. It's crucial to use non-confrontational approaches when dealing with clients experiencing manic episodes to prevent increased agitation and aggression.

Choice B rationale:

Ignoring the client's behavior is not a suitable approach, as it could lead to a deterioration of the situation and potentially compromise the safety and well-being of both the client and others on the unit. It's important to address disruptive behavior promptly and appropriately.

Choice C rationale:

Asking the client to recommend consequences for her disruptive behavior might not be effective during a manic episode. Clients in a manic state might not have a realistic or rational perspective on their behavior, and involving them in determining consequences could lead to unreasonable outcomes.

A. Instruct the client to sit down and stop pacing. B. Have a staff member escort the client to her room. C. Walk with the client at a gradually slower pace. D. Allow the client to pace alone until physically tired.

Correct Answer is C

Explanation

The correct answer is choice C. Walk with the client at a gradually slower pace.

Choice A rationale:

Instructing the client to sit down and stop pacing (Choice A) might come across as authoritarian and dismissive of the client's anxiety. It's important to provide a more supportive and empathetic approach.

Choice B rationale:

Having a staff member escort the client to her room (Choice B) might further escalate the client's anxiety. The client may interpret this action as a form of containment or punishment.

Choice C rationale:

Walk with the client at a gradually slower pace (Choice C) is the most appropriate action. This approach acknowledges the client's anxiety and provides a calming presence. Gradually slowing down can help the client naturally transition from pacing to a calmer state.

Choice D rationale:

Allowing the client to pace alone until physically tired (Choice D) might prolong the episode of anxiety. Providing support and engagement is essential in managing the client's distress effectively.

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A home health nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is experiencing a manic episode. Other clients begin to complain about her disruptive behavior on the unit. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting, and now the client is pacing up and down the hallways of the unit. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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