A home health nurse is visiting a client who has advanced Alzheimer's disease.
The client's partner states, "I miss being able to go places with my friends.”. Which of the following is an appropriate response by the nurse?
"We can discuss this when you're not feeling overwhelmed.”.
"Have you tried taking your partner with you when you go out?"
"Tell me more about your expectations.”.
"I understand how you feel. I've had a relative go through the same thing.”
The Correct Answer is C
Choice A rationale
Telling the client's partner to discuss their feelings when not feeling overwhelmed is dismissive. It does not address their current emotional state or offer support. This response can make the partner feel unheard and may not provide immediate relief or understanding.
Choice B rationale
Suggesting that the partner take the client with them when going out may not be practical, especially considering the advanced stage of Alzheimer's disease. This response can show a lack of understanding of the challenges faced by caregivers of individuals with severe cognitive impairment.
Choice C rationale
Asking the partner to share more about their expectations opens a dialogue and shows empathy. It allows the nurse to understand the partner’s feelings and needs better, providing an opportunity for supportive and individualized advice.
Choice D rationale
While expressing understanding and sharing a personal experience might build rapport, it can shift the focus away from the partner's feelings and needs. The nurse should remain client-centered, providing support specific to the partner's situation rather than comparing it to their own.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B,A,C,D,E
Explanation
Choice A rationale
Unlocking and removing the inner cannula is the first step. It allows access to the inner cannula for cleaning and ensures that the tracheostomy tube remains patent.
Choice B rationale
Pouring 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin provides the necessary solution for cleansing the inner cannula and stoma site, helping to maintain sterility and prevent infection.
Choice C rationale
Scrubbing the inside and outside of the inner cannula with a small brush ensures that any mucus or debris is removed, reducing the risk of infection and maintaining clear airways.
Choice D rationale
Wiping the inside of the inner cannula with a folded pipe cleaner helps to remove any remaining debris or solution, ensuring that the inner cannula is thoroughly cleaned.
Choice E rationale
Cleansing the stoma site with 0.9% sodium chloride solution helps to remove any mucus or debris from the site, maintaining hygiene and reducing the risk of infection.
Correct Answer is C
Explanation
Choice A rationale
Injecting air into the ampule prior to drawing the medication into a syringe can cause the medication to spill and is not a safe practice.
Choice B rationale
Adding 0.5 mL of diluent to the medication is not a standard procedure for medication administration from an ampule and can lead to incorrect dosing.
Choice C rationale
Using a filter needle to aspirate the medication is important to prevent glass particles from the broken ampule from entering the syringe and being administered to the patient.
Choice D rationale
Cleansing the tip of the ampule with an alcohol swab after opening is unnecessary, as the medication is already inside the sealed ampule, and it can increase the risk of contamination.
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