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 ["A","B","C","E"]
Explanation
Choice A rationale:
Tachycardia (rapid heart rate) is a potential physical symptom of alcohol withdrawal. When alcohol-dependent individuals suddenly stop or reduce their alcohol intake, it can lead to increased sympathetic nervous system activity, resulting in elevated heart rate.
Choice B rationale:
Tremors (shakes) are common during alcohol withdrawal due to the suppression of the central nervous system by alcohol. Abrupt cessation of alcohol can lead to overactivity in the nervous system, resulting in tremors.
Choice C rationale:
Hallucinations can occur during alcohol withdrawal and are usually visual or tactile in nature. These hallucinations are often referred to as alcoholic hallucinosis and can be distressing for the individual experiencing them.
Choice E rationale:
Seizures can be a severe consequence of alcohol withdrawal. Known as alcohol withdrawal seizures, these episodes can occur within the first 48 hours after cessation of heavy alcohol consumption and are attributed to the hyperexcitability of the central nervous system.
Choice D rationale:
Hypotension (low blood pressure) is not typically associated with alcohol withdrawal. In fact, alcohol withdrawal often leads to an increase in blood pressure and heart rate due to the hyperactivity of the sympathetic nervous system.
Correct Answer is D
Explanation
Choice A rationale:
Periods of elation with unusual talkativeness. Rationale: While periods of elation with unusual talkativeness can be associated with certain mental health conditions, such as bipolar disorder, they are not specific to schizophrenia. These symptoms are more indicative of mania, which is characteristic of bipolar disorder.
Choice B rationale:
Recurrent thoughts of past trauma. Rationale: Recurrent thoughts of past trauma can be associated with various mental health disorders, including post-traumatic stress disorder (PTSD), but they are not specific to schizophrenia. Schizophrenia is primarily characterized by disturbances in thought processes, perception, and behavior.
Choice C rationale:
Preoccupied with folding clothes. Rationale: Preoccupation with folding clothes is not a hallmark symptom of schizophrenia. Schizophrenia is characterized by symptoms such as hallucinations, delusions, disorganized thinking, and impaired social functioning.
Choice D rationale:
Invents words that have no meaning. Rationale: This statement is correct. Inventing words that have no meaning, also known as "neologisms," is a symptom often observed in individuals with schizophrenia. Neologisms are a manifestation of disorganized thinking and communication.
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