Exhibit. The spouse of a male client with early-stage Alzheimer's disease (AD) tells the nurse, "I am just exhausted from the constant worry. I don't know what to do." Which action is best for the nurse to take next? (Select All That Apply.)

Suggest that a long-term care facility be considered.

Offer ideas for ways to distract or redirect the client.

Ask the spouse what she knows and has considered about dementia care options.

Educate the spouse about the availability of adult care as a respite.

Suggest that the spouse consults with the physician for anti-anxiety drugs.

Answer and Explanation

Correct Answer : B,D

The correct answers are choices B and D: "Offer ideas for ways to distract or redirect the client." and "Educate the spouse about the availability of adult care as a respite."

Choice A rationale:

Suggesting a long-term care facility should not be the first action. Early-stage Alzheimer's clients can often remain at home with proper support, and suggesting institutionalization might not be appropriate at this stage.

Choice B rationale:

This is a correct choice. Engaging the client with Alzheimer's in activities that distract or redirect their focus can be helpful. This approach can alleviate the spouse's concerns and provide some relief from exhaustion.

Choice C rationale:

While discussing dementia care options with the spouse is important, it might not directly address the spouse's current exhaustion and feelings of helplessness.

Choice D rationale:

This is a correct choice. Educating the spouse about adult care options for respite can provide much-needed breaks for the caregiver. Caring for someone with Alzheimer's can be emotionally and physically draining, so respite care can offer temporary relief.

Choice E rationale:

Suggesting anti-anxiety drugs for the spouse is not the best first action. While addressing caregiver stress is important, suggesting medication should come after considering other supportive measures.

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Correct Answer is A

Explanation

Choice A rationale:

(Correct) Severe anxiety can lead to a fight-or-flight response, which might manifest as aggressive behavior. The individual might feel threatened and react defensively, potentially displaying aggressive actions to protect themselves.

Choice B rationale:

Attention-seeking conduct is less likely to be a primary manifestation of severe anxiety. While individuals with anxiety might seek reassurance or attention, the level of anxiety described here is more likely to evoke a defensive response rather than attention-seeking behavior.

Choice C rationale:

Mild fidgeting can be a manifestation of anxiety, but in the context of severe anxiety, the physical symptoms are often more pronounced, including restlessness, trembling, and muscle tension.

Choice D rationale:

Mild difficulty problem-solving is less likely to be a prominent manifestation of severe anxiety. Severe anxiety tends to affect the individual's ability to function and cope, leading to more intense and immediate reactions.

A. "You need to work hard on resolving conflict with those closest to you.” B. "Let's discuss what you mean when you say that you cannot ever return to work.” C. "I notice you keep clenching your fists. Why are you doing this?” D. "Antidepressants are not your solution, but this therapy group is.”

Correct Answer is B

Explanation

Choice A rationale:

Telling the newly diagnosed cancer clients that they need to work hard on resolving conflicts with those closest to them may come across as insensitive and dismissive of their emotional struggles. Cancer diagnosis often brings about complex emotions, and this response does not acknowledge or address their concerns.

Choice B rationale:

This response acknowledges the client's statement and encourages further discussion about their feelings regarding their inability to return to work. It shows empathy and a willingness to explore their concerns, promoting open communication and emotional support.

Choice C rationale:

Commenting on the client's physical behavior without context might make them uncomfortable or self-conscious. The nurse's observation about fist clenching should be addressed more delicately if relevant, and the focus should be on the emotional aspect rather than the physical behavior.

Choice D rationale:

Dismissing the potential benefit of antidepressants and promoting the therapy group might undermine the client's feelings and choices. While group therapy can be beneficial, this response overlooks the potential need for a multifaceted approach to treatment, which could include therapy and medication.

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Exhibit. The spouse of a male client with early-stage Alzheimer's disease (AD) tells the nurse, "I am just exhausted from the constant worry. I don't know what to do." Which action is best for the nurse to take next? (Select All That Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse at a walk-in mental health clinic is assessing a client experiencing severe anxiety. The nurse should recognize the client might exhibit which of the following manifestations?

Correct Answer is A

Explanation

A nurse is leading a group therapy session for clients who are newly diagnosed with cancer. Which of the following statements should be an appropriate response by the nurse?

Correct Answer is B

Explanation

A nurse is assessing a client diagnosed with schizophrenia. Which of the following behaviors should the nurse document to be associated with schizophrenia?

Exhibit. The spouse of a male client with early-stage Alzheimer's disease (AD) tells the nurse, "I am just exhausted from the constant worry. I don't know what to do." Which action is best for the nurse to take next? (Select All That Apply.)

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 caring for an older adult client who was alert and oriented at admission but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs?

A nurse is taking care of an adult client who is experiencing increased anxiety and an inability to concentrate. Which of the following responses should the nurse make?