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 D

Explanation

The correct answer is choice d. When removing a peripheral IV catheter, the nurse uses scissors to remove the tape that secures the catheter.

Choice A rationale:

Inserting the tip of the enema tube 8 cm (3.1 in) is within the recommended range for adults, which is typically 7.5 to 10 cm (3 to 4 in). This action does not require intervention.

Choice B rationale:

Elevating the head of the bed when caring for a client’s body after death is a standard practice to prevent discoloration of the face and to facilitate drainage. This action does not require intervention.

Choice C rationale:

Using a clean washcloth, soap, and water for indwelling catheter care is appropriate and follows infection control guidelines. This action does not require intervention.

Choice D rationale:

Using scissors to remove the tape that secures a peripheral IV catheter is unsafe as it poses a risk of cutting the catheter or the client’s skin. This action requires intervention to ensure the nurse uses a safer method, such as using adhesive remover or gently peeling the tape away by hand.

A. Move the client using a slider board. B. Use an air-assisted transfer device to move the client. C. Raise the bed to 5 cm (2 in) above the level of the stretcher. D. Position the head of the bed at 25° prior to the transfer.

Correct Answer is B

Explanation

Choice A rationale:

Moving the client using a slider board might be appropriate for transferring clients with relatively lower weight and mobility challenges. However, in this scenario, where the client weighs 136 kg (300 lb), a more advanced transfer method is necessary to ensure the safety of both the client and the healthcare providers.

Choice B rationale:

Using an air-assisted transfer device is suitable for transferring clients with higher weight, as it helps reduce friction and strain during the transfer process. This approach ensures a smoother transfer and minimizes the risk of injury to both the client and the assistive personnel.

Choice C rationale:

Raising the bed to 5 cm (2 in) above the level of the stretcher might not provide enough clearance for a safe transfer. Additionally, the use of assistive devices is more appropriate for transferring clients with significant weight, rather than relying solely on adjusting the bed height.

Choice D rationale:

Positioning the head of the bed at 25° prior to the transfer is not directly relevant to the process of transferring a client from a bed to a stretcher. The focus should be on using appropriate equipment and techniques for safe and efficient transfer, especially considering the client's weight.

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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 is observing a newly licensed nurse provide client care. Which of the following actions by the newly licensed nurse requires intervention by the nurse?

Correct Answer is D

Explanation

A nurse is preparing to transfer a client who weighs 136 kg (300 lb) from a bed to a stretcher with the aid of an assistive personnel (AP). Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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