A nurse is caring for a client who has late-stage Alzheimer's disease and is hospitalized for treatment of the flu. During the night shift, the client is found climbing into the bed of another client who becomes upset and scared. Which of the following actions should the nurse take?

Assist the client to the correct room.

Medicate the patient with antipsychotics.

Move the client to a room at the end of the hall.

Place the client in restraints.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The nurse should prioritize the safety and well-being of both clients involved. Assisting the client with late-stage Alzheimer's disease to the correct room is important to prevent any further confusion or distress. Alzheimer's disease often causes cognitive impairment, memory loss, and disorientation, which can lead to situations where the individual may not recognize their surroundings or the people around them. Guiding the client back to their own room will help reduce confusion, agitation, and potential conflicts with other clients.

Choice B rationale:

Medicating the patient with antipsychotics is not the most appropriate initial action in this situation. Antipsychotic medications are often used to manage severe behavioral disturbances associated with conditions like schizophrenia or dementia, but their use should be carefully considered due to potential side effects. In this scenario, addressing the immediate situation and guiding the client back to their room is more appropriate than resorting to medication.

Choice C rationale:

Moving the client to a room at the end of the hall is not the best choice because it doesn't directly address the current situation. While changing the client's room might be considered in some cases to reduce agitation or wandering, it's not the immediate action needed when the client is found in another client's bed. Guiding the client to the correct room is the priority.

Choice D rationale:

Placing the client in restraints is not an appropriate choice in this situation. Restraints should only be used as a last resort for ensuring the safety of the client or others when less restrictive interventions have failed. Placing a client with Alzheimer's disease in restraints can be traumatic and lead to increased agitation and psychological distress.

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Correct Answer is B

Explanation

The correct answer is choice B: Maintain a nonjudgmental attitude.

Choice A rationale:

Verbalize disapproval of the client's substance abuse. Expressing disapproval can create a negative environment and hinder the therapeutic relationship. Judgmental attitudes can make clients feel defensive and less likely to open up about their struggles.

Choice B rationale:

Maintain a nonjudgmental attitude. Maintaining a nonjudgmental attitude is crucial in building trust and rapport with clients. It creates an environment where clients feel safe discussing their issues without fear of criticism. A nonjudgmental attitude encourages open communication and helps the nurse gather relevant information to provide appropriate care.

Choice C rationale:

Offer sympathetic support. While offering support is important, sympathy might inadvertently convey pity or enable the client's behavior. Empathy, where the nurse understands and shares the client's feelings without judgment, is more effective in building a therapeutic relationship.

Choice D rationale:

Avoid displaying an emotional response. While it's important for the nurse to maintain professionalism, avoiding any emotional response might come across as cold or detached. Expressing appropriate empathy and emotions can actually enhance the therapeutic relationship.

A. Ask the client direct questions about the hallucination. B. Act to the client as if the hallucination is real. C. Tell the client to go to their room and they should go away. D. Instruct the client to argue with the voices that are a part of the hallucination.

Correct Answer is A

Explanation

The correct answer is choice A. Ask the client direct questions about the hallucination.

Choice A rationale:

Asking direct questions about the hallucination helps the nurse understand the client’s experience and assess the content and intensity of the hallucinations. This approach also allows the nurse to provide appropriate support and interventions.

Choice B rationale:

Acting as if the hallucination is real can reinforce the client’s distorted perception of reality, which is not therapeutic. The nurse should acknowledge the client’s experience without validating the hallucination as real.

Choice C rationale:

Telling the client to go to their room and that the hallucinations should go away is dismissive and does not address the client’s immediate needs. It is important to engage with the client and provide support rather than dismiss their experience.

Choice D rationale:

Instructing the client to argue with the voices can increase the client’s distress and is not a recommended therapeutic approach. Instead, the nurse should help the client find ways to cope with and manage the hallucinations.

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A nurse is caring for a client who has late-stage Alzheimer's disease and is hospitalized for treatment of the flu. During the night shift, the client is found climbing into the bed of another client who becomes upset and scared. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is interviewing a client during admission to an alcohol treatment center. Which of the following approaches should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client diagnosed with schizophrenia and is experiencing hallucinations. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse on a mental health unit observes a diagnosed schizophrenic patient on antipsychotics having an impaired gait and uncontrollable tremors. The nurse should recognize that which of the following adverse effects may be occurring?

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