A nurse is discussing home care concerns with the son of a client who has Alzheimer's disease. The son states, "I am so tired all the time, but Mom needs me." Which of the following responses should the nurse make?

"You should think about placing your mother in a long-term care facility."

I think you should find other family members who could help your mother."

"You owe it to your mother to take care of her now that she needs you."

"Let me give you some information about respite care for your mother."

Answer and Explanation

The Correct Answer is D

This response acknowledges the son's exhaustion and offers a constructive solution by suggesting respite care. Respite care provides temporary relief to caregivers by arranging for someone else to take over caregiving responsibilities for a specific period of time.

It allows caregivers to have a break and take care of their own physical and emotional well-being. By providing information about respite care, the nurse is offering support and resources to help alleviate the son's fatigue while ensuring that the mother's care needs are still met.

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Correct Answer is C

Explanation

Overhearing a discussion about a client's private information is a breach of confidentiality, and it is the nurse's responsibility to address the situation promptly.

While documenting the event in the client's progress notes might be necessary in some cases, it is not the initial action to take in this scenario. Similarly, submitting an incident report to the risk manager may be required for documentation purposes, but it is not the immediate action to address the breach of confidentiality.

Informing the client of the APs' actions may not be necessary unless there is evidence that the client's privacy has been compromised or if the client specifically requests to know. However, the priority is to address the issue of the conversation between the APs and ensure that confidentiality is maintained.

A. Wears a face mask around others B. Increased intake of green, leafy vegetables C. Uses a firm-bristled toothbrush D. Sleeps 8 to 10 hr per night

Correct Answer is C

Explanation

A.Wearing a face mask does not increase the risk of injury. In fact, it helps protect the client from infections, especially if they have concurrent neutropenia, which is common in conditions affecting the bone marrow.

B.Green, leafy vegetables are rich in vitamin K, which plays a role in clotting. However, they do not directly increase the risk of injury in a client with thrombocytopenia. While vitamin K affects clotting factors, thrombocytopenia primarily involves a deficiency of platelets, which are necessary for clot formation.

C.Clients with thrombocytopenia have a low platelet count, which increases their risk of bleeding. Using a firm-bristled toothbrush can cause gum trauma and bleeding, leading to complications such as prolonged bleeding or infection. A soft-bristled toothbrush or an alternative oral hygiene method (such as an oral swab) is recommended to minimize injury.

D.Adequate sleep does not increase the risk of injury. In fact, it may support overall health and immune function.

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A nurse is discussing home care concerns with the son of a client who has Alzheimer's disease. The son states, "I am so tired all the time, but Mom needs me." Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse overhears two assistive personnel (AP) in the nurses' station discussing a client who was recently admitted. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is collecting data from a client who has thrombocytopenia. The nurse should identify that which of the following findings increases the client's risk for injury?

Correct Answer is C

Explanation

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