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:

Applying intermittent suction for up to 30 seconds is incorrect. While suctioning is necessary for tracheostomy care, the duration and frequency of suctioning should be based on the client's need and should typically last no more than 10-15 seconds to prevent hypoxemia and tissue damage.

Choice B Reason:

Preoxygenate the client prior to suctioning is correct. Preoxygenation helps ensure that the client has adequate oxygen levels before the suctioning procedure, reducing the risk of hypoxemia or decreased oxygen levels during and after suctioning

Choice C Reason:

Instruct the client to swallow during catheter insertion is incorrect. Instructing the client to swallow during catheter insertion is not a standard procedure for tracheostomy care. Swallowing doesn't have a direct association with the suctioning process.

Choice D Reason:

Apply suction while inserting the catheter is incorrect. Applying suction during catheter insertion can cause tissue damage and should be avoided. Suction should only be applied when withdrawing the catheter to remove secretions from the tracheostomy tube.

A. Ask the client to state their room number. B. Have the client state their phone number. C. Request an assistive personnel to identify the client. D. Review the client's photograph in the medical record.

Correct Answer is D

Explanation

Choice A Reason:

Asking the client to state their room number is incorrect. A client with advanced dementia might not reliably remember or be able to state their room number, so this might not be a reliable method for identification.

Choice B Reason:

Having the client state their phone number is incorrect. Similar to the room number, relying on the client to state their phone number might not be feasible or reliable in cases of advanced dementia.

Choice C Reason:

Requesting an assistive personnel to identify the client is incorrect. While asking another staff member might seem practical, it might not ensure accurate identification, especially if the personnel is not directly involved in the client's care or isn't familiar enough with the client's identity due to frequent rotations or duties.

Choice D Reason:

Reviewing the client's photograph in the medical record is correct. Reviewing the client's photograph in the medical record is a reliable method to confirm the client's identity, especially in cases where the client might have difficulty providing other personal information due to advanced dementia.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse in a long-term care facility is preparing to administer medications to a client who has advanced dementia and does not have an identification band. Which of the following actions should the nurse take to verify the client's identity?

Correct Answer is D

Explanation

A nurse is planning to provide postmortem care for a client who requires an autopsy. Which of the following actions should the nurse plan to take?

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