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
Explanation
The correct answer is choice A: Request a mental health consult.
Choice A rationale:
Requesting a mental health consult is the first priority in this situation. The client's significant weight loss, distorted body image, and belief that she is fat suggest potential body dysmorphic disorder, eating disorder, or other psychological concerns. It's crucial to address these underlying issues before focusing on other aspects of care.
Choice B rationale:
Providing a structured environment can be beneficial, but it might not address the root cause of the client's psychological distress and distorted body image.
Choice C rationale:
Assessing the client's nutritional status is important to understand the physical impact of the weight loss, but the urgent need here is to address the client's psychological well-being and distorted self-perception.
Choice D rationale:
Planning a therapeutic diet for the client is essential, but it should not be the first priority. The client's belief that she is fat and her significant weight loss indicate deeper psychological issues that require immediate attention. Without addressing these psychological concerns, focusing solely on a diet plan might exacerbate her distorted body image and eating behaviors.
Correct Answer is D
Explanation
Choice A rationale:
Administering medication to sedate the client is not the appropriate initial action. The client's confusion and restlessness could be due to various factors, and administering sedative medication without identifying the cause of these symptoms could lead to adverse effects or mask underlying issues.
Choice B rationale:
Calling the family to stay with the client might provide emotional support, but it doesn't directly address the client's safety needs. The client's increasing confusion and restlessness require a more immediate intervention to ensure their safety.
Choice C rationale:
Applying wrist and leg restraints should be a last resort and is not the appropriate initial action in this situation. Restraints should only be used if less restrictive interventions have failed and the client's safety is at risk. Restraints can lead to complications such as decreased mobility, skin breakdown, and increased agitation.
Choice D rationale:
Correct Choice Moving the client to a room closer to the nurses' station is the most appropriate action in this scenario. This intervention helps to increase the client's visibility and proximity to nursing staff, making it easier to monitor and address their needs promptly. It also promotes a safer environment while allowing the healthcare team to assess the underlying causes of the restlessness and confusion.
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