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 D

Explanation

The correct answer is choice D: "Remain with the client in his room for a while."

Choice D rationale:

This choice is the correct answer because when a client is experiencing panic-level anxiety, their immediate need is for support and reassurance. Staying with the client helps establish a sense of safety and demonstrates the nurse's presence, which can help reduce anxiety. Providing a calming and supportive presence is a therapeutic nursing intervention in this situation.

Choice A rationale:

Medicating the client with a sedative might be appropriate in some cases of severe anxiety, but it should not be the first action taken. Non-pharmacological interventions, such as offering emotional support, should be prioritized before resorting to medication.

Choice B rationale:

Joining a therapy group might be beneficial for the client in the future, but during the acute phase of panic-level anxiety, the client might not be in a state to actively participate and engage in group therapy. Immediate individual attention is necessary.

Choice C rationale:

While suggesting that the client rest in bed could be helpful for relaxation, it might not be sufficient to address the intensity of panic-level anxiety. The client might not be able to rest or calm down without more direct support from the nurse.

A. Approach the client frequently throughout the day for brief interactions. B. Disclose some personal information to the client to demonstrate approachability. C. Adopt a neutral attitude when providing care. D. Wait for the client to initiate interaction.

Correct Answer is C

Explanation

Choice A rationale:

Approaching the client frequently throughout the day for brief interactions might exacerbate the client's suspiciousness and discomfort. Individuals who are extremely suspicious may interpret frequent approaches as intrusive or manipulative, leading to increased agitation or withdrawal.

Choice B rationale:

Disclosing personal information to the client in an attempt to demonstrate approachability is not recommended. Sharing personal information can blur professional boundaries and may not necessarily address the client's suspicion. It's important to build trust gradually through consistent, respectful, and professional interactions.

Choice C rationale:

Adopting a neutral attitude when providing care is appropriate because it helps create a non-threatening environment. Individuals who are suspicious may interpret overly friendly or emotionally charged behavior as insincere or manipulative. A neutral and respectful approach allows the client to feel more comfortable and safe in the nurse's presence.

Choice D rationale:

Waiting for the client to initiate interaction may not be effective in establishing a therapeutic relationship. Extremely suspicious clients might be hesitant to initiate interactions due to their mistrust. Nurses should take the initiative to approach clients with suspicion in a respectful and neutral manner to gradually build rapport and trust.

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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 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?

Correct Answer is D

Explanation

A nurse is caring for a client who is extremely suspicious of the nursing staff and other clients. Which of the following nursing approaches is appropriate when establishing a therapeutic relationship with this client?

Correct Answer is C

Explanation

A nurse is interviewing a client during admission to an alcohol treatment center. Which of the following approaches should the nurse take?

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A nurse is taking care of a client who is cognitively impaired. The nurse recognizes that which of the following rooms will provide a therapeutic environment for this client?

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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?

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?

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