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:

Performing oral care once each day is not sufficient to reduce the risk of ventilator-associated pneumonia (VAP). Ventilated patients are at an increased risk of developing VAP due to the presence of an endotracheal tube that bypasses the body's natural defenses. Bacteria can accumulate in the mouth and respiratory tract, leading to pneumonia. Therefore, performing oral care only once a day is inadequate for maintaining oral hygiene and preventing VAP.

Choice B rationale:

Brushing the client's teeth with a firm-bristle toothbrush can cause trauma to the oral tissues, potentially leading to bleeding and irritation. In critically ill patients with an endotracheal tube, using a firm-bristle toothbrush can exacerbate the risk of infection and VAP. It is essential to use gentle and non-traumatic methods for oral care to maintain the integrity of the oral mucosa.

Choice C rationale:

Swabbing the client's mouth with chlorhexidine solution is the correct choice. Chlorhexidine is an antiseptic solution that effectively reduces the growth of bacteria in the oral cavity. Regular use of chlorhexidine mouthwash has been shown to decrease the risk of VAP in mechanically ventilated patients. By reducing the bacterial load in the mouth, the risk of aspiration and subsequent pneumonia is lowered, making it a crucial intervention for preventing VAP.

Choice D rationale:

Raising the head of the bed by 15° for oral care is an important measure to prevent aspiration during oral care. However, it alone is not sufficient to reduce the risk of VAP. While proper head positioning helps prevent the entry of oral secretions into the lower respiratory tract, it must be combined with effective oral hygiene practices, such as using chlorhexidine solution, to comprehensively reduce the risk of VAP.

A. Teach the most crucial content early in the session. B. Assume that the learners have no prior knowledge of first aid. C. Avoid repetition of procedures and techniques. D. Divide the planned program into several sessions held about 1 week apart.

Correct Answer is A

Explanation

Choice A rationale:

Teaching the most crucial content early in the session is an effective strategy to engage learners and ensure that they receive essential information. This approach captures their attention and provides a solid foundation for the rest of the session. It helps establish relevance and interest, keeping the learners engaged throughout the educational program.

Choice B rationale:

Assuming that learners have no prior knowledge of first aid might not be the best approach. Adult learners often come with varying levels of knowledge and experience. It's important to assess the learners' prior knowledge and adjust the content accordingly to avoid redundancy or information that is too basic for them.

Choice C rationale:

Repetition of procedures and techniques is a valuable teaching strategy. Repetition aids in retention and comprehension. Reiterating important points reinforces learning and helps participants remember critical steps in first aid procedures. Avoiding repetition can lead to incomplete understanding and retention.

Choice D rationale:

Dividing the planned program into several sessions held about 1 week apart might not be the most effective strategy for community education. Spacing the sessions too far apart could result in learners forgetting the content or losing interest. It's better to maintain a consistent schedule to ensure continuity and engagement.

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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 planning care for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following interventions should the nurse include to reduce the client's risk for ventilator-associated pneumonia?

Correct Answer is C

Explanation

A nurse is planning a community education session about the basic principles of first aid. Which of the following teaching strategies should the nurse implement for a group of adult learners in a community setting?

Correct Answer is A

Explanation

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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?

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?

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A nurse receives a telephone call from a client's family member, who asks the nurse for an update on the client's condition. Which of the following actions should the nurse take to maintain the client's confidentiality?