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.”

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

A repressed grief response, where an individual avoids expressing their grief, is considered delayed grief, not exaggerated grief. This can manifest as physical symptoms or psychological issues later on.

Choice B rationale

Grief that begins following a terminal diagnosis is anticipatory grief, which is a normal response as individuals begin to process the impending loss. It prepares them emotionally for the eventual death.

Choice C rationale

Exaggerated grief involves intense, prolonged, and often harmful reactions such as self-destructive behaviors. This type of grief can significantly impair a person's ability to function and may require professional intervention.

Choice D rationale

A grief response triggered by a secondary loss (e.g., loss of job or home) is known as cumulative grief. While it complicates the grieving process, it does not inherently lead to the exaggerated, self-destructive behaviors seen in exaggerated grief.

A. Place the specimen in a clean specimen cup. B. Remove 45 mL of urine from the catheter with a syringe. C. Clamp the catheter tubing below the needleless port. D. Clamp the catheter tubing for 60 min.

Correct Answer is C

Explanation

Choice A rationale

Placing the specimen in a clean specimen cup is not appropriate for a urine culture and sensitivity test. A sterile specimen cup is required to avoid contamination and ensure accurate results.

Choice B rationale

Removing 45 mL of urine from the catheter with a syringe is incorrect. Only 5-10 mL of urine is needed for a culture and sensitivity test, and excessive removal can lead to inaccurate test results or sample contamination.

Choice C rationale

Clamping the catheter tubing below the needleless port is the correct action. This allows urine to accumulate in the tubing, providing a fresh and uncontaminated sample for the culture and sensitivity test.

Choice D rationale

Clamping the catheter tubing for 60 minutes is too long and can cause urine stasis, increasing the risk of catheter-associated urinary tract infections. The tubing should be clamped only for a short duration to collect an adequate sample. .

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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?

Nursing Test Bank

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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?