The nurse is assessing an older adult client who is having difficulty remembering events from earlier in the day and concentrating on the questions being asked. A family member shares that the client's home was recently sold and the client has just moved in with them. Which nursing response best promotes effective communication with the family?

Delirium is often a sign of underlying mental illness, and institutionalization is often necessary.

If the dementia is a result of Alzheimer's disease, it is often reversible even in the late stages.

The client's delirium may be due to depression and is possibly reversible.

The client is exhibiting symptoms of dementia, and because of age, it may be permanent.

Answer and Explanation

The Correct Answer is C

Choice A reason: Suggesting that delirium is often a sign of underlying mental illness and that institutionalization is necessary can be distressing and may not be accurate without further assessment.

Choice B reason: Stating that dementia due to Alzheimer's disease is often reversible even in the late stages is incorrect; Alzheimer's disease is a progressive condition with no current cure.

Choice C reason: Recognizing the possibility of delirium due to depression, which can be reversible, is a hopeful and constructive approach that encourages further evaluation and treatment options.

Choice D reason: Suggesting that symptoms of dementia are permanent because of age can be disheartening and does not consider the potential for reversible causes of cognitive impairment.

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

Explanation

The correct answer is: A. Teach the client to use an incentive spirometer every 2 hours while awake and E. Remove the urinary catheter as soon as possible and encourage voiding.

Choice A reason:

Teaching the client to use an incentive spirometer every 2 hours while awake helps prevent postoperative pulmonary complications such as pneumonia. This intervention promotes lung expansion and clears secretions, reducing the risk of infection.

Choice B reason:

Administering low molecular weight heparin as prescribed is important for preventing deep vein thrombosis (DVT) and pulmonary embolism, but it does not directly reduce the risk of infection.

Choice C reason:

Assessing the pain level and medicating as needed is crucial for patient comfort and mobility, but it does not directly address infection prevention. Effective pain management can indirectly support recovery by enabling better mobility and respiratory function.

Choice D reason:

Maintaining sequential compression devices while in bed is aimed at preventing DVT, not infections. These devices help improve blood circulation and reduce the risk of blood clots.

Choice E reason:

Removing the urinary catheter as soon as possible and encouraging voiding reduces the risk of catheter-associated urinary tract infections (CAUTIs). Prompt removal of the catheter minimizes the duration of exposure to potential pathogens, thereby reducing infection risk.

A. Measure body temperature. B. Assess skin turgor. C. Check for pedal edema. D. Observe the color of urine.

Correct Answer is D

Explanation

Choice A reason: Measuring body temperature is a standard procedure but not directly related to monitoring for adverse effects of prasugrel, which primarily include bleeding complications.

Choice B reason: Assessing skin turgor is generally used to evaluate hydration status and is not specific to prasugrel's adverse effects.

Choice C reason: Checking for pedal edema can indicate heart failure or vascular problems but is not a direct indicator of prasugrel's adverse effects.

Choice D reason: Observing the color of urine is important as prasugrel can cause significant and sometimes fatal bleeding. Dark or bloody urine may be an early indicator of such bleeding.

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Naxlex Comprehensive Predictor Exams

An older adult client is admitted for the repair of a broken hip. To reduce the risk of infection in the postoperative period, which nursing care interventions should the nurse include in the client's plan of care? Select all that apply.

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

Explanation

Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this client's plan of care?

Correct Answer is D

Explanation

A client is being discharged home after being treated for heart failure (HF). Which instruction should the nurse include in this client's discharge teaching plan?

A client who is one day postpartum reports to the nurse that her baby cannot latch onto the breast. The nurse observes that the client's nipples are inverted. Which action should the nurse implement?

A nurse is caring for a client who has been prescribed parenteral lidocaine. Before administering the medication, the nurse should review the medical record for which condition?

A client is admitted with the diagnosis of Wernicke's syndrome. Which assessment finding should the nurse use in planning the client's care?

The healthcare provider prescribes ear drops to an adult client with an ear infection. Which teaching should the nurse provide?

An older adult male client arrives at the clinic reporting that his bladder always feels full. The client also reports a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating the urine stream. Which action should the nurse implement?

The nurse implements a primary prevention program for sexually transmitted diseases in a nurse-managed health center. Which outcome indicates that the program was effective?