The nurse is assessing an older 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?

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

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

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

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

Answer and Explanation

The Correct Answer is C

Given the client's difficulty with memory, concentration, and recent life changes, it is

important for the nurse to acknowledge the possibility of delirium as a potential cause of the client's symptoms. Delirium is an acute state of confusion that can be caused by various factors, including physical illness, medication side effects, and emotional stressors. It is often reversible when the underlying cause is identified and treated.

By mentioning the possibility of delirium and its potential reversibility, the nurse opens up the conversation to exploring other factors that may be contributing to the client's symptoms. This response also provides hope to the family by suggesting that the client's condition may improve with appropriate interventions and management.

Stating that dementia resulting from Alzheimer's disease is often reversible even in the late stages is incorrect. Alzheimer's disease is a progressive neurodegenerative disorder that currently has no cure, and the symptoms tend to worsen over time.

Reversibility is not typically associated with Alzheimer's disease.

Indicating that the client's symptoms of dementia are permanent due to age is a generalization and may not be accurate. While age is a risk factor for certain types of dementia, such as Alzheimer's disease, it does not mean that all memory and cognitive difficulties in older adults are irreversible.

Suggesting that delirium is often a sign of underlying mental illness and institutionalization is necessary is not appropriate. Delirium is a medical condition that requires thorough assessment and appropriate management, including addressing any underlying causes. Institutionalization may be considered in certain situations, but it is not the primary focus of communication in this context.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A) Incorrect- Dizziness is a common side effect of ramelteon and may occur initially as the body adjusts to the medication. While it's important to monitor and address dizziness, it may not require immediate reporting unless it's severe or persistent.

B) Incorrect- A change in the sleep-wake cycle is expected when using medications to treat sleep disorders. Ramelteon is designed to help regulate sleep patterns, so a change in the sleep-wake cycle is an anticipated effect.
C) Incorrect- Mild sedation is a common side effect of ramelteon and is usually well-tolerated.

It's important to educate the client about potential sedation effects and advise them not to engage in activities that require full alertness until they know how the medication affects them.
D) Correct- Somnambulism, also known as sleepwalking, is a potentially dangerous side effect that needs immediate attention from the healthcare provider. The client's safety is at risk due to the potential for injury during sleepwalking episodes.

A. Maintain strict intake and output. B. Assess warmth of extremities. C. Keep head of bed raised 45 degrees. D. Monitor blood glucose level.

Correct Answer is A

Explanation

Septic shock is a life-threatening condition characterized by a severe infection that leads to systemic inflammation, organ dysfunction, and low blood pressure. Maintaining strict intake and output monitoring is essential to assess the client's fluid balance and response to interventions. It allows the nurse to closely monitor the client's urine output, which is a crucial indicator of renal perfusion and overall organ function.

Monitoring urine output helps the nurse assess the adequacy of tissue perfusion and the client's response to fluid resuscitation. A decrease in urine output can be an early sign of worsening organ dysfunction and a need for further interventions.

While assessing the warmth of extremities is important for evaluating peripheral perfusion, maintaining strict intake and output monitoring takes priority as it provides more comprehensive information about the client's overall fluid status.

Raising the head of the bed 45 degrees (semi-Fowler's position) can help optimize respiratory function and reduce the risk of aspiration, but it is not the most important intervention in this case.

Monitoring blood glucose levels is important, as hyperglycemia can be associated with sepsis. However, in the context of septic shock, maintaining strict intake and output monitoring takes precedence as it directly assesses the client's fluid balance and response to interventions.

It's crucial to note that the management of septic shock requires a multidisciplinary approach, and other interventions, such as administering appropriate antibiotics, initiating fluid resuscitation, and addressing the underlying source of infection, should also be implemented in a timely manner.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing severe side effects since taking the drug. Which side effect should the nurse report to the healthcare provider?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

The nurse is preparing to administer 1.6 mL of medication intramuscularly to a 4-month-old infant. Which action should the nurse include?

A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider's attention?

A client tells the nurse about jogging every day with the hope of losing weight and sleeping better. The client states that it takes hours to fall asleep at night and is experiencing fatigue and sleepiness throughout the day. Which action should the nurse implement?

A client who is receiving zidovudine reports the appearance of pinpoint, red, round spots on the skin. Which result should the nurse report to the healthcare provider?

The nurse is performing an admission assessment for a newborn who has asymmetrical buttocks. Which assessment test results should the nurse report to the healthcare provider?

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?

The practical nurse (PN) reports that a client who has a fingerstick glucose of 35 mg/dL (1.94 mmol/L) is alert and diaphoretic. Which action should the charge nurse take? Reference Ranges Glucose [Reference Range: 0 to 50 years: 74 to 106 mg/dL (4.1 to 5.9 mmol/L)]