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 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. .
Correct Answer is A
Explanation
Choice A rationale
Avoid placing toilet tissue in the bedpan after defecation to prevent contamination of the stool specimen. Toilet tissue can introduce foreign substances that may interfere with lab results.
Choice B rationale
Urinate after the specimen collection is incorrect because urine can contaminate the stool sample. The client should urinate before collecting the stool specimen to avoid mixing the two.
Choice C rationale
Placing 1.3 cm (0.5 in) of formed stool into a culture tube is insufficient for a proper stool sample. Typically, a larger sample is needed to ensure enough material is available for testing.
Choice D rationale
Keeping the specimen in a warm area is incorrect because stool samples should be kept in a cool environment to preserve the integrity of the specimen until it can be analyzed.
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