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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A pounding headache in a client with COPD may be a symptom of increased carbon dioxide (CO2) levels in the blood, known as hypercapnia. Hypercapnia can lead to vasodilation, resulting in headaches. In this situation, it is crucial to assess the client's blood pressure to determine if it is elevated, as this could be contributing to the headache.
Obtaining a manual blood pressure measurement allows for a more accurate assessment of the client's blood pressure compared to automated measurements. It is important to assess both systolic and diastolic blood pressures, as elevated blood pressure can worsen headaches and have other negative effects on the client's health.
Elevating the head of the bed no higher than 30 degrees is a general measure used to improve respiratory function in clients with COPD. However, in this specific situation, it may not directly address the pounding headache. Elevating the head of the bed can help reduce dyspnea and improve oxygenation, but it may not alleviate the headache caused by hypercapnia.
Affirming blood glucose levels are below 160 mg/dL (8.88 mmol/L) is not the primary concern in this case. While high blood glucose levels can have various effects on the body, including headaches, the priority is to assess the client's blood pressure due to the specific context of a COPD exacerbation.
Checking for a stat intravenous diuretic prescription is not necessary in response to the client's headache. Diuretics are typically used to remove excess fluid from the body and may not directly address the underlying cause of the headache in this situation.
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.
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