A home health nurse is visiting a client who has advanced Alzheimer's disease. The client's partner states, "I miss being able to go places with my friends." Which of the following is an appropriate response by the nurse?

"We can discuss this when you're not feeling overwhelmed."

"I understand how you feel. I've had a relative go through the same thing."

"Have you tried taking your partner with you when you go out?"

"Tell me more about your expectations."

Answer and Explanation

The Correct Answer is D

Choice A Reason:

"We can discuss this when you're not feeling overwhelmed." Is incorrect. This response acknowledges the partner's feelings but doesn't directly address their concern about missing social outings. It offers to revisit the topic later, which might be helpful, but it doesn't provide immediate support or suggestions.

Choice B Reason:

"I understand how you feel. I've had a relative go through the same thing." Is incorrect. While expressing empathy is essential, comparing experiences might inadvertently minimize the partner's feelings. Each situation is unique, and the partner might need specific advice or support tailored to their circumstances.

Choice C Reason:

"Have you tried taking your partner with you when you go out?" is incorrect. This response suggests a potential solution by proposing involving the client with Alzheimer's in social outings. However, in advanced stages, this might not always be feasible or suitable due to the nature of the condition. It's essential to be sensitive to the client's needs and abilities.

Choice D Reason:

"Tell me more about your expectations." Is correct. This response invites the partner to share more about their feelings and desires without assuming a solution. It opens a dialogue to understand the partner's concerns and expectations better, allowing the nurse to offer appropriate support or guidance.

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Correct Answer is B

Explanation

Choice A Reason:

"He appears anxious about the transfer."While this might be relevant in certain contexts, it is subjective and less critical compared to other clinical information. The transfer report should prioritize objective data that directly impacts the client’s care.

Choice B Reason:

"He is allergic to sulfa." Allergies are crucial information that must be communicated during any transfer. This ensures that the receiving healthcare team is aware and can avoid administering medications that could cause an allergic reaction. This is important information to include in the transfer report.

Choice C Reason:

"His partner has been visiting." While it may be helpful to know about the client’s support system, this information is not as critical as details about the client's health status, medications, or allergies.

Choice D Reason:

"He is voiding adequately." Voiding patterns can be relevant, particularly if there have been recent issues with urinary function or if the client is being monitored for urinary output. However, unless there is a specific reason this is critical to ongoing care, it may not be the most essential information to include.

A. Use a filter needle to aspirate the medication B. Add 0.5 ml of diluent to the medication, C. Cleanse the tip of the ampule with an alcohol swab after opening. D. Inject air into the ampule prior to drawing the medication into a syringe.

Correct Answer is A

Explanation

Choice A Reason:

A filter needle is used to prevent any glass particles from entering the syringe when drawing medication from an ampule, as ampules are made of glass that can sometimes break and leave shards.

Choice B Reason:

Adding 0.5 ml of diluent to the medication is incorrect. Adding diluent to medication from an ampule is not a standard practice. Ampules usually contain pre-measured doses of medication and are designed for direct withdrawal without dilution. Adding diluent could alter the concentration and effectiveness of the medication.

Choice C Reason:

The ampule should be cleansed before opening to remove any potential contaminants. Once the ampule is opened, the inside of the ampule and the medication should be considered sterile, so there is no need to cleanse the tip after opening.

Choice D Reason:

Injecting air into the ampule prior to drawing the medication into a syringe is incorrect. This action is not typically necessary when withdrawing medication from an ampule. Some medications may require air to equalize pressure, but it's crucial to follow specific guidelines for each medication. In most cases, creating positive pressure by injecting air into the ampule is not recommended, as it could affect the stability or integrity of the medication.

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A home health nurse is visiting a client who has advanced Alzheimer's disease. The client's partner states, "I miss being able to go places with my friends." Which of the following is an appropriate response by the nurse?

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Naxlex Comprehensive Predictor Exams

A nurse is transferring a client to another unit. Which of the following statements should the nurse include in the transfer report?

Correct Answer is B

Explanation

A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?

Correct Answer is A

Explanation

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