A nurse observes a client's spouse sitting alone in the waiting room crying. When approached, the spouse says, "I am really concerned about my husband." Which of the following is an appropriate response by the nurse?

"Tell me what is concerning you.”

"Crying helps us let things out and we feel better.”

"Your husband is making really good progress.”

"Did your husband say something to upset you?”

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The correct choice. In this situation, the nurse's priority is to gather information and provide emotional support. By asking the spouse to share their concerns, the nurse opens up a channel of communication and shows empathy, creating an opportunity to address the spouse's worries and provide reassurance.

Choice B rationale:

While the sentiment that crying can be cathartic and relieving is true, this response does not directly address the spouse's concern or encourage them to share their feelings. It's important to focus on the spouse's feelings rather than just explaining the benefits of crying.

Choice C rationale:

Assuming that the husband is making progress without knowing the specifics of the situation can come across as dismissive of the spouse's concerns. It's important to validate the spouse's emotions and provide support, rather than making assumptions about the husband's progress.

Choice D rationale:

Asking whether the husband said something to upset the spouse might be relevant, but it does not address the spouse's expressed concern about their husband. This response may not foster open communication and emotional support as effectively as choice A.

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Correct Answer is A

Explanation

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.

A. A client requests extra blankets when the thermostat in the room indicates 25.6°C (78°F). B. A client attempts to climb out of bed and repeatedly states she must get home. C. A client refuses to get out of bed and has no motivation to attend to daily hygiene. D. A client wants to know the current time while there is a clock on the wall.

Correct Answer is B

Explanation

The correct answer is choice B.

Choice A rationale:

A client requesting extra blankets due to a room temperature discrepancy is not indicative of delirium. This behavior may simply stem from feeling cold, which is a logical response to a temperature below the client's comfort level.

Choice B rationale:

A client attempting to climb out of bed and repeatedly stating a need to get home is a manifestation of delirium. Delirium is characterized by sudden disturbances in consciousness and cognitive function, leading to confusion and altered perception. The client's behavior suggests a disoriented state and a distorted perception of reality.

Choice C rationale:

A client refusing to get out of bed and lacking motivation for daily hygiene might not necessarily indicate delirium. These symptoms could be related to other factors, such as depression or physical discomfort, which are not specific to delirium.

Choice D rationale:

A client wanting to know the current time when there is a visible clock on the wall doesn't indicate delirium. It might just reflect the client's desire to know the time, which is a common behavior and doesn't directly relate to cognitive disturbances associated with delirium.

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A nurse observes a client's spouse sitting alone in the waiting room crying. When approached, the spouse says, "I am really concerned about my husband." Which of the following is an appropriate response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

A nurse is caring for a group of older adult clients. Which of the following manifestations indicates one of the clients is experiencing delirium?

Correct Answer is B

Explanation

A nurse on an inpatient mental health unit is admitting a client who has panic-level anxiety. After orienting the client to his room, which of the following nursing actions is most therapeutic at this time?

A nurse is caring for a client diagnosed with a mental illness on a psychiatric unit. Which of the following actions by the nurse demonstrates the ethical concept of autonomy?

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.).

A nurse is creating a plan of care for a client who is experiencing mania. Which of the following interventions should the nurse include in the plan?

A nurse is taking care of a client who has generalized anxiety disorder and is taking buspar (Buspirone). Which of the following adverse effects should the nurse report to the provider?

A nurse is planning care for a client newly admitted with major depressive disorder. After ensuring safety, which of the following actions should the nurse plan to take?

A nurse on a mental health unit notices that a client is becoming increasingly agitated and throws a table when he is unable to select the television (TV) channel. Which of the following should be a priority action by the nurse?