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. Perceives himself as inferior to others. B. Desires to be the center of attention. C. Believes that others are deceiving him. D. Continuously holds onto grudges. E. Exhibits a grandiose sense of self-importance.

Correct Answer is ["C","D"]

Explanation

The correct answer is choice c. Believes that others are deceiving him, and choice d.Continuously holds onto grudges

Choice A rationale:

Perceiving oneself as inferior to others is more characteristic of avoidant personality disorder, where individuals often avoid social situations due to feelings of inadequacy and fear of rejection.

Choice B rationale:

Desiring to be the center of attention is a trait often seen in histrionic personality disorder, where individuals crave attention and may use dramatic behavior to achieve it.

Choice C rationale:

Individuals with paranoid personality disorder tend to have a pervasive and unjustified mistrust of others. They often believe that others are deceiving, exploiting, or harming them, even in the absence of evidence to support these beliefs. This mistrust is a central characteristic of this disorder.

Choice D rationale:

Continuously holding onto grudges is another hallmark feature of paranoid personality disorder. These individuals are prone to bearing grudges and being unforgiving, as they are hypersensitive to perceived slights or insults.

Choice E rationale:

Exhibiting a grandiose sense of self-importance is more characteristic of narcissistic personality disorder, where individuals have an inflated sense of their own importance and often lack empathy for others.

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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 is caring for a client who has paranoid personality disorder. Which of the following findings should the nurse expect? (Select all that apply.).

Correct Answer is ["C","D"]

Explanation

During a family group therapy session, the nurse overhears the client telling her daughter, "You need to do better in school so I can love you as much as I love your brother." According to Warren, this statement discourages the development of positive self-esteem by hindering which parenting focus?

When providing community healthcare teaching regarding the early warning signs of Alzheimer's disease, which signs should the nurse advise family members to report (Select all that apply)?

A nurse in a mental health clinic is attempting to develop a therapeutic relationship with a client. Which of the following should be the appropriate action by the nurse?

A client has made the decision to leave her alcoholic husband and reports feeling very depressed. Which of the following is a non-therapeutic statement by the nurse that demonstrates sympathy?

The nurse is caring for a client diagnosed with Severe Intellectual Disability. Which of the following characteristics should the nurse recognize to be associated with Severe Intellectual Disability?

A nurse in the ER is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?

A nurse is assessing a client who has illness anxiety disorder. Which of the following findings should the nurse expect?