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The nurse is performing a history and physical assessment for a client in the clinic with moderate dementia. The client becomes agitated when asked questions and inquires why so many questions are being asked. What are the best actions for the nurse to take to obtain the necessary data? Select all that apply.

Persistently ask the same question until answered.

Give the client ample time to answer the questions asked.

Ask simple questions instead of compound questions.

Provide simple explanations to the client as often as required.

Take frequent breaks during the interview process.

Answer and Explanation

Correct Answer : B,C,D,E

Choice A reason: Persistently asking the same question can increase agitation in clients with dementia.

Choice B reason: Allowing ample time for responses can reduce pressure and agitation in clients with dementia.

Choice C reason: Simple questions are easier for clients with dementia to understand and respond to.

Choice D reason: Providing simple explanations can help clients with dementia understand the purpose of the questions.

Choice E reason: Taking frequent breaks can help prevent fatigue and agitation during the assessment process.

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Correct Answer is A

Explanation

Choice A reason: Weight gain is indeed a known side effect of lithium treatment, and acknowledging this can validate the client's experience.

Choice B reason: This response could be perceived as blaming and does not acknowledge that weight gain can be a side effect of lithium.

Choice C reason: This statement is misleading as weight gain can occur beyond the first month of treatment with lithium.

Choice D reason: This statement is incorrect as weight loss is not the typical pattern associated with lithium; weight gain is more common.

A. "I think it is the shampoo and conditioner my child is using." B. "I have watched my child pull hair out and try to hide it." C. "I started losing some hair at a young age and think it is just shedding." D. "My child doesn't appear to be nervous or upset about anything."

Correct Answer is B

Explanation

Choice A reason: While it's possible for hair products to cause hair loss, this does not typically result in the loss of eyebrow hair.

Choice B reason: This statement suggests the child may be experiencing trichotillomania, a condition characterized by the urge to pull out one's hair.

Choice C reason: Genetic factors could contribute to hair loss, but the statement does not directly suggest a behavioral issue like trichotillomania.

Choice D reason: The absence of nervousness or upset does not rule out trichotillomania, as the behavior may not necessarily be linked to visible emotional distress.

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Naxlex Comprehensive Predictor Exams

A client began taking lithium for the treatment of bipolar disorder approximately one month ago. The client asks if it is normal to have gained 12 pounds in this time frame. Which is the appropriate nursing reply?

Correct Answer is A

Explanation

The nurse is performing an assessment for a young adolescent and observes a lack of hair on the eyebrows and the hairline. Which statement made by the parent demonstrates an understanding of the type of hair loss the child is experiencing?

Correct Answer is B

Explanation

The nurse is talking with a client who grew up in a home where both parents were alcoholics. Which behaviors does the nurse identify when assessing this client that correlate with this home life? Select all that apply.

A nurse is educating the family of an adolescent client with anorexia nervosa about the issues surrounding this eating disorder. Which statement made by the parent indicates that the education is effective?

The nurse is performing a history and physical assessment for a client in the clinic with moderate dementia. The client asks the nurse why all of these questions are being asked. Which techniques will the nurse most likely avoid using to foster more therapeutic responses? Select all that apply.

A female client comes to the clinic regularly for various somatic issues that have been ruled out for any organic cause. She states that she works as one of the only women on a cybersecurity technical team. Which statement made by the client indicates that she may have suppressed anger?

A nurse in an acute care mental health facility is preparing to administer morning medication to a client who has been taking lithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the following actions should the nurse take?

When a community health nurse arrives at the home of a client diagnosed with Bulimia Nervosa, what family dynamic is most likely contributing to the client's condition?

The nurse is caring for a client who delivered a newborn 2 days ago and states that they are experiencing crying spells, anxiety, and sadness that started the day after delivery. Which is the most therapeutic action by the nurse?