A nurse is caring for a client who has Alzheimer's disease and appears anxious. The client asks the nurse to stay at their bedside. Which of the following responses should the nurse make to reduce the client's anxiety?

"Does your family know that you are feeling anxious?".

"Tell me about where you lived when you were growing up.".

"Let's talk after I finish caring for my other clients.".

"Why are you feeling anxious?".

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Inquiring whether the client's family knows about their anxiety is not directly related to addressing the client's current anxiety. The focus should be on the client's feelings and needs rather than involving the family in this particular instance.

Choice B rationale:

This choice is the most appropriate response. Asking the client to share memories from their past redirects their attention from the current anxiety-provoking situation. Discussing positive memories can help alleviate anxiety and provide comfort to the client.

Choice C rationale:

Suggesting to talk later after caring for other clients dismisses the client's immediate need for support and comfort. It's essential to address the client's anxiety promptly rather than delaying the discussion.

Choice D rationale:

Asking the client why they are feeling anxious might put them on the spot and could potentially escalate their anxiety. Instead of prompting them to explain the cause of their anxiety, the nurse should focus on providing reassurance and distraction.

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Correct Answer is C

Explanation

Choice A rationale:

A client who needs assistance when ambulating is an important consideration for care, but it does not necessarily require a priority referral. The nurse can assess the client's mobility and coordinate assistance within the rehabilitation unit as needed.

Choice B rationale:

A client who consistently has difficulty using utensils while eating is a concern for occupational therapy or speech therapy, but it is not an immediate priority. The client's difficulty with eating utensils can be addressed through therapeutic interventions within the rehabilitation setting.

Choice C rationale:

A client who has expressive aphasia requires a priority referral because this indicates potential communication difficulties that could hinder the client's ability to express needs, understand instructions, and participate in therapy. Expressive aphasia can impact the client's overall rehabilitation progress and safety.

Choice D rationale:

A client who consistently coughs after drinking liquids might require assessment and intervention, but it does not present an immediate priority. The nurse can address this concern within the rehabilitation unit and collaborate with the interdisciplinary team as needed.

A. The nurse administered enoxaparin 40 mg subcutaneous to a client using the deltoid site for injection. B. The nurse advanced the urinary catheter 18 cm (7 in) when inserting an indwelling urinary catheter for a male client. C. The nurse cleanses a wound with 0.99% sodium chloride irrigation prior to collecting a specimen for culture. D. The nurse flushed the tubing of a continuous enteral feeding with 30 mL of water.

Correct Answer is ["A","B","D"]

Explanation

Choice A rationale:

Administering medication, such as enoxaparin, via an inappropriate route (deltoid site) is a medication error and requires an incident report. The deltoid muscle is not recommended for subcutaneous injections due to the risk of incorrect absorption or injection-related complications.

Choice B rationale:

Inserting a urinary catheter too far into the male client (18 cm or 7 inches) can cause potential harm or trauma to the urethra or bladder. This situation requires an incident report, as it signifies a deviation from proper medical procedure.

Choice C rationale:

Cleansing a wound with normal saline irrigation prior to collecting a culture specimen is a routine nursing practice and does not typically warrant an incident report. This action is part of the standard procedure for preventing contamination of the culture sample.

Choice D rationale:

Flushing enteral feeding tubing with water is a standard practice to ensure proper delivery of nutrition. Flushing tubes with water, unless contraindicated for the specific patient, is a normal procedure and does not require an incident report.

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A nurse is caring for a client who has Alzheimer's disease and appears anxious. The client asks the nurse to stay at their bedside. Which of the following responses should the nurse make to reduce the client's anxiety?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a rehabilitation unit is assessing a group of clients who have a traumatic brain injury. The nurse should identify that which of the following clients requires a priority referral?

Correct Answer is C

Explanation

A nurse is caring for a group of clients. Which of the following client-care situations requires the nurse to complete an incident report?

Correct Answer is ["A","B","D"]

Explanation

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A nurse is planning to assist a client who has left-sided weakness to ambulate using a gait belt. Which of the following actions should the nurse plan to take?

A nurse is caring for a client who reports using alcohol and controlled substances to cope with the death of their partner. The nurse should identify that maladaptive coping is an indication of which of the following types of complicated grief?

A nurse is teaching a client about self-administering a subcutaneous injection to the abdomen. Which of the following instructions should the nurse include?