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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","B","C","D"]

Explanation

Choice A reason: Assessing strengths and weaknesses realistically helps the client to understand their capabilities and limitations post-withdrawal.

Choice B reason: Verbalizing plans to join a community support group indicates the client's commitment to ongoing recovery and support after discharge.

Choice C reason: Receiving only prescribed medications ensures the client does not relapse into drug use and maintains the treatment plan's integrity.

Choice D reason: Initiating interactions with others in the facility can help the client rebuild social skills and integrate into a community, which is beneficial for recovery.

Choice E reason: While sharing feelings is important, setting a specific timeframe such as 48 hours may not be realistic for every client and can vary based on individual readiness.

A. "Did your husband say something to upset you?" B. "Tell me what is concerning you." C. "Your husband is making really good progress!" D. "Did something bad happen to your husband?"

Correct Answer is B

Explanation

The correct answer is: "Tell me what is concerning you."

Choice A reason:

Asking "Did your husband say something to upset you?" may seem accusatory and could lead the spouse to feel defensive. It does not open a dialogue for the spouse to express their concerns freely and can be perceived as leading the conversation in a negative direction.

Choice B reason:

"Tell me what is concerning you." is an open-ended statement that invites the spouse to share their feelings and concerns. It demonstrates empathy and active listening, which are key components of therapeutic communication. This response encourages the spouse to elaborate on their feelings and fosters a supportive environment.

Choice C reason:

Saying "Your husband is making really good progress!" is reassuring, but it does not address the spouse's current emotional state or concerns. It may come across as dismissive of the spouse's feelings and does not encourage further discussion about their worries.

Choice D reason:

Asking "Did something bad happen to your husband?" can increase anxiety and assumes a negative event has occurred. It is not a therapeutic response because it does not provide comfort or support to the spouse in a stressful situation.

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Naxlex Comprehensive Predictor Exams

The nurse is planning the care of a client with bipolar disorder and addiction to heroin who is in a rehabilitation facility. Which outcomes will the nurse assign in the immediate phase after withdrawal symptoms are over? (Select all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

A nurse observes a client's spouse sitting alone in the waiting room crying. When approached, the spouse says, "I am really concerned about my husband." Which of the following is a therapeutic nursing response?

Correct Answer is B

Explanation

The nurse is working to develop a therapeutic nurse-client relationship with a client diagnosed with paranoid personality disorder. Which techniques will the nurse use to foster trust? Select all that apply.

A community health nurse is providing teaching to the family of a client who has primary dementia. Which of the following manifestations should the nurse tell the family to expect?

A nurse is working with clients diagnosed with personality disorders. Which techniques would be most important for the nurse to use to effectively deal with the frustration in providing care to this group of clients? Select all that apply.

A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following? Select all that apply.

Which of the following statements is associated with a client's child experiencing hair loss?

The nurse is planning an approach that will be most effective in developing a therapeutic relationship with a client. Which disorder(s) will the nurse best employ a matter-of-fact approach with the client? (Select all that apply.)

A client and their spouse come to talk with the nurse about their suspicion that the client may have intermittent explosive disorder after researching it on the internet. Which behaviors reported by the spouse indicate that the client may be experiencing this disorder? (Select all that apply.)