The primary caregiver of a client with newly diagnosed Alzheimer's disease states "I don't know how I will handle caring for my spouse with this disease". What is the nurse's best first response?
"You sound overwhelmed, can you tell me more?"
"It will take time, but lot's of people do it"
"What do you think will be the hardest thing to handle?"
"The entire health care team will manage most of the disease process
The Correct Answer is A
Choice A Rationale: "You sound overwhelmed, can you tell me more?" is an empathetic response that encourages the caregiver to express their feelings and concerns. It opens the door for effective communication and understanding.
Choice B Rationale: "It will take time, but lots of people do it" may be true, but it does not directly address the caregiver's emotional state or offer support.
Choice C Rationale: "What do you think will be the hardest thing to handle?" is a probing question that can help identify specific concerns, but it may not be the most appropriate initial response.
Choice D Rationale: "The entire healthcare team will manage most of the disease process" does not acknowledge the caregiver's emotions and concerns and may not provide the needed support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Rationale: Assessing the client for bladder distention is the first and most crucial step in managing autonomic dysreflexia. Bladder distention is a common trigger for this condition in clients with spinal cord injuries. Identifying and addressing the cause (bladder distention) is the priority to prevent further complications.
Choice B Rationale: Laying the client flat may not resolve the underlying cause of autonomic dysreflexia and should be done after identifying and addressing the trigger.
Choice C Rationale: Obtaining the client's heart rate is important but should come after assessing for bladder distention since the primary concern in autonomic dysreflexia is elevated blood pressure due to a noxious stimulus.
Choice D Rationale: Administering a nitrate antihypertensive may be necessary if other interventions do not resolve the blood pressure elevation, but it should not be the first action. Identifying and addressing the cause, such as bladder distention, is the priority.
Correct Answer is C
Explanation
Choice A Rationale: Oral care is important for overall hygiene but may not take precedence over other critical aspects of care for a client with a spinal cord injury.
Choice B Rationale: Offering the client to discuss their feelings is important for emotional support but may not be the highest priority.
Choice C Rationale: Diet modifications are a high priority because they are essential for addressing the client's nutritional needs and preventing complications related to the spinal cord injury, such as pressure ulcers and infections.
Choice D Rationale: The application of compression stockings may have a role in the care plan but is not typically the highest priority for a client with a spinal cord injury.
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