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 - While a salad includes vegetables and fruits, it may not provide sufficient protein for wound healing.
B) Incorrect - Vegetable soup and crackers might not provide enough protein compared to other options.
C) Incorrect - While a peanut butter sandwich includes some protein, soda and cookies are not rich sources of protein.

D) Correct- A tuna fish sandwich is a good source of protein. Protein is essential for wound healing as it supports tissue repair and regeneration. The choice of a tuna fish sandwich along with chips and ice cream suggests a balanced meal with adequate protein content, which aligns with the teaching of a high protein diet to promote wound healing.

A. Report any increase in the white blood cell count. B. Instruct the family to adhere to contact precautions. C. Change the surgical dressing readily when soiled. D. Wear a face mask while performing wound care.

Correct Answer is B

Explanation

MRSA is a highly contagious bacteria that can easily spread from person to person through direct contact or contact with contaminated surfaces. By instructing the family to adhere to contact precautions, the nurse can help prevent the spread of MRSA to the client's postoperative wound. Contact precautions typically involve wearing gloves and a gown when in direct contact with the client or the client's immediate environment.

While reporting any increase in the white blood cell count, changing the surgical dressing when soiled, and wearing a face mask during wound care are all important aspects of postoperative care, they are not specifically targeted at preventing the recurrence of MRSA. Adhering to contact precautions is the most effective measure to prevent the spread of MRSA and protect the client from further infection.

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

The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client Indicates that the teaching was effective?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

The nurse is caring for a client after a thoracentesis that drained 50 mL of clear fluid from the left lung. Which assessment finding should the nurse report to the healthcare provider immediately?

When providing community healthcare teaching regarding the early warning signs of Alzheimer's disease, which signs should the nurse advise family members to report (Select all that apply)?

The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behavior(s) indicate the client understands how to maintain balance safely? (Select all that apply.)

The nurse is triaging several children as they present to the emergency room after a school bus accident. Which child requires the most immediate intervention by the nurse?

After a spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which admission assessment finding(s) should the nurse report to the healthcare provider? (Select all that apply.)

Patient Data History and Physical Nurses' Notes Laboratory Results Flow Sheet Exhibits here Review H and P, nurse's note, laboratory result, and flow sheet. What information should the nurse collect as part of the focused assessment for dehydration in this child? Select all that apply.

The parent of a child born with a myelomeningocele asks the nurse, "What did I do to deserve this?" Which response is most helpful?