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 A

Explanation

Choice A rationale:

Demonstrating genuineness involves being authentic, sincere, and transparent in interactions with clients. This helps build trust by showing that the nurse's intentions and emotions align with their words. Genuineness fosters a sense of safety and openness in the therapeutic relationship.

Choice B rationale:

While focusing on the words of the clients is important, it's not the only factor. Nonverbal cues, emotions, and context also play significant roles in effective communication. Only focusing on words could result in missing important nuances and emotions.

Choice C rationale:

Controlling the pace of the nurse-client relationship contradicts the principle of client-centered care, where the client's readiness and comfort should guide the pace. Pushing the pace might lead to resistance or discomfort, hindering the development of trust.

Choice D rationale:

Providing sympathy involves expressing pity or sorrow for the client's situation. However, empathy, which involves understanding and sharing the client's feelings, is more appropriate. Sympathy might create a sense of pity, while empathy establishes a deeper connection and understanding.

A. Ask the client for permission to take photographs. B. Provide community sexual assault support contacts. C. Document the client's verbatim statements. D. Determine any physical signs of injury.

Correct Answer is C

Explanation

Answer: c. Document the client's verbatim statements.

Here's why the other options are wrong:

a. Ask the client for permission to take photographs:While photographs may be collected as evidence later, it should not be the first priority. The priority is to focus on patient care and emotional well-being.
b. Provide community sexual assault support contacts:Offering support resources is important, but documenting the details of the assault is crucial for forensic and legal purposes, and should come first.
d. Determine any physical signs of injury:Looking for physical injuries is important, but documenting the client's account should come first. This ensures the client's narrative is captured accurately and can be referred to later.

Documenting the client's verbatim statements is the most important initial action because:

It preserves the client's account of the assault in their own words.
It allows for accurate reporting and investigation.
It can be used as evidence in legal proceedings.

Here are some supporting points:

The Rape, Abuse & Incest National Network (RAINN):"Law enforcement will need to take a detailed statement about the assault, and a medical professional will likely perform a physical exam. Be prepared to answer questions about what happened." [1]
The National Sexual Assault Hotline:"Law enforcement will want to get a statement from you as soon as possible after the assault. Try to remember the details of the assault as clearly as you can." [2]

In conclusion, while all the other options are important aspects of caring for a sexual assault survivor, documenting the client's verbatim statements is the most critical initial action for a nurse to take in the emergency department setting.

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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 psychiatric nurse is caring for clients on a mental health unit during a group session. What should the nurse do to establish trust in a therapeutic relationship with the clients?

Correct Answer is A

Explanation

A nurse in an emergency department is performing an assessment on a client who reports being sexually assaulted. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse in an acute care mental health facility is assessing a client who has bipolar disorder. The nurse recognizes that which of the following findings indicates the client is at risk for suicide?

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A nurse notices that a client who has moderate anxiety is pacing the corridor and rambling. As the nurse approaches, the client states, "I am at the end of my rope. I don't think I can take any more bad news." Which of the following responses should the nurse make?

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A nurse is reviewing the history and physical of an adolescent client diagnosed with conduct disorder. The nurse recognizes that which of the following is an expected assessment finding of conduct disorder?

A nurse is admitting an older adult client to the unit who has a suspected cognitive disorder. Which of the following inventories should be included as part of the admission assessment?

The nurse is asking a diagnosed schizophrenic patient how they slept and they respond, "This is a new day in May and I can't wait to play." Which communication pattern does the nurse identify?

A home health nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain?