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 small amount of liquid stool draining from the stoma is expected during the early postoperative period following colostomy placement. This indicates that the stoma is functioning and passing waste as intended.

Choice B rationale

The stoma protruding slightly from the abdomen, known as stoma protrusion or eversion, is a common and normal finding. It indicates that the stoma is correctly positioned and healing properly.

Choice C rationale

A dark-colored stoma is a concerning sign that indicates compromised blood flow to the stoma tissue, potentially leading to necrosis. This requires immediate medical attention to address the underlying cause and prevent further complications.

Choice D rationale

Light bleeding from the stoma when touched is normal in the immediate postoperative period. The stoma tissue is highly vascular, and minor bleeding is expected as it heals and forms new tissue connections.

A. Pad bony prominences before applying a restraint. B. Tie the ends of the restraint to the client's bed rail. C. Use a square knot to secure the client's restraint to the bed. D. Observe the client's skin integrity every 2 hr. E. Ensure that 2 fingers can be placed between the restraint and the client.

Correct Answer is ["A","D","E"]

Explanation

Choice A rationale

Pad bony prominences before applying a restraint to prevent skin breakdown and pressure sores. Bony areas are prone to pressure ulcers when subjected to prolonged pressure from restraints.

Choice B rationale

Restraint ends should never be tied to the client's bed rail because it can lead to injury if the bed rail is moved or adjusted. Proper technique involves securing restraints to a part of the bed frame that does not move.

Choice C rationale

A square knot should not be used to secure the client's restraint as it can be difficult to untie in an emergency. Instead, quick-release knots or buckle straps are preferred for safety and rapid removal.

Choice D rationale

Observing the client's skin integrity every 2 hours is crucial to identify any signs of skin irritation, pressure ulcers, or other complications early. Regular checks ensure prompt intervention if issues arise.

Choice E rationale

Ensuring that two fingers can be placed between the restraint and the client helps to maintain proper circulation and comfort, preventing too tight a restraint which can lead to circulatory and nerve damage.

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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

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy.Which of the following findings should the nurse report to the provider?

Correct Answer is C

Explanation

A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about the proper use of restraints.Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

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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?