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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale: Planning a therapeutic diet is essential for the client's recovery. However, it is not the first priority. Understanding the client's nutritional needs and current deficiencies should come before creating a diet plan.
Choice B rationale: Providing a structured environment is important to ensure the client follows the treatment plan and receives the appropriate support. However, it comes after assessing the client's current state and needs.
Choice C rationale: Assessing the client's nutritional status is the first priority because it provides critical information about the client's current health and guides all other aspects of care. Without knowing the client's nutritional status, it is challenging to make informed decisions about her treatment plan.
Choice D rationale: Requesting a mental health consult is important, especially given the client's belief that she is fat and the significant weight loss. However, before addressing her psychological needs, the nurse must understand her physical health status to provide comprehensive care.
Correct Answer is C
Explanation
Choice A rationale:
Instructing the client to tell the voices to leave them alone oversimplifies the situation. It disregards the distress and lack of control that individuals with schizophrenia often experience when hearing voices. This response may also imply that the client has complete control over the voices, which is not accurate.
Choice B rationale:
Denying the existence of the voices contradicts the client's experience and could lead to further distrust between the client and nurse. Acknowledging the client's feelings and experiences is essential for building rapport and understanding in a therapeutic relationship.
Choice C rationale:
This response is appropriate because it acknowledges the client's experience and seeks to understand the content and nature of the voices. It demonstrates empathy and encourages open communication, which is crucial in providing effective care for individuals with schizophrenia.
Choice D rationale:
Asking the client why they think they are hearing the voices might be interpreted as confrontational or judgmental. It could make the client defensive and hinder open communication. Instead, focusing on the content of the voices allows the nurse to gain insight into the client's experiences without placing blame.
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