Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assisting with the plan of care for a client who has Alzheimer's disease. Which of the following actions should the nurse recommend for the plan of care?
A. Encourage the client to talk about current events.
Encourage the client to talk about current events: While social interaction and engagement are beneficial for clients with Alzheimer's disease, their ability to comprehend and discuss current events may be limited due to cognitive impairments. It is important to adapt communication to the client's cognitive abilities and interests.
B. Give directions using simple phrases
When assisting with the plan of care for a client with Alzheimer's disease, it is important to consider their cognitive impairments and provide appropriate interventions. Giving directions using simple phrases is recommended because it helps the client beter understand and follow instructions. Complex or lengthy directions can be confusing and overwhelming for individuals with Alzheimer's disease. Using clear and concise language can enhance communication and facilitate the client's ability to engage in activities of daily living.
C. Orient the client to time and place twice per day
Orient the client to time and place twice per day: Frequent orientation to time and place can be helpful for clients with Alzheimer's disease, but the specific frequency should be based on the individual's needs and preferences. Some individuals may require more frequent orientation, while others may find it overwhelming. The plan of care should be individualized to address the client's specific needs.
D. Rotate assistive personnel to help the client with ADLs
Rotate assistive personnel to help the client with ADLs: Consistency and familiarity are important for individuals with Alzheimer's disease. Rotating assistive personnel frequently may disrupt the client's routine and cause increased confusion and agitation. Whenever possible, it is best to maintain a consistent caregiving team to provide familiarity and establish a therapeutic relationship with the client
This question is an excerpt from Nurse Dive's nursing test bank - VATI PN Comprehensive Predictor 2020 Proctored Exam. Take the full exam now
Full Explanation
b. Give directions using simple phrases.
The correct answer is b. Give directions using simple phrases.
Explanation:
When assisting with the plan of care for a client with Alzheimer's disease, it is important to consider their cognitive impairments and provide appropriate interventions. Giving directions using simple phrases is recommended because it helps the client beter understand and follow instructions. Complex or lengthy directions can be confusing and overwhelming for individuals with Alzheimer's disease. Using clear and concise language can enhance communication and facilitate the client's ability to engage in activities of daily living.
Explanation for the other options:
a. Encourage the client to talk about current events: While social interaction and engagement are beneficial for clients with Alzheimer's disease, their ability to comprehend and discuss current events may be limited due to cognitive impairments. It is important to adapt communication to the client's cognitive abilities and interests.
c. Orient the client to time and place twice per day: Frequent orientation to time and place can be helpful for clients with Alzheimer's disease, but the specific frequency should be based on the individual's needs and preferences. Some individuals may require more frequent orientation, while others may find it overwhelming. The plan of care should be individualized to address the client's specific needs.
d. Rotate assistive personnel to help the client with ADLs: Consistency and familiarity are important for individuals with Alzheimer's disease. Rotating assistive personnel frequently may disrupt the client's routine and cause increased confusion and agitation. Whenever possible, it is best to maintain a consistent caregiving team to provide familiarity and establish a therapeutic relationship with the client.
In summary, giving directions using simple phrases is an appropriate action when assisting with the plan of care for a client with Alzheimer's disease. This approach promotes effective communication and enhances the client's ability to understand and follow instructions.
Similar Questions
A nurse is caring for a client who is receiving total parenteral nutrition. Which of the following laboratory results indicates a possible complication of this therapy?
A. Serum calcium 12.5 mg/dL
A nurse caring for a client who is receiving total parenteral nutrition should identify that a serum calcium level of 12.5 mg/dL indicates a possible complication of this therapy. Total parenteral nutrition can result in electrolyte imbalances, including hypercalcemia (high levels of calcium in the blood).
B. BUN 16 mg/dL
A BUN level of 16 mg/dLis within the normal range.
C. Serum potassium 4.6 mEq/L
A serum potassium level of 4.6 mEq/L is within the normal range.
D. WBC count 8,000/mm³
A WBC count of 8,000/mm³is within the normal range.
Full Explanation
A nurse caring for a client who is receiving total parenteral nutrition should identify that a serum calcium level of 12.5 mg/dL indicates a possible complication of this therapy. Total parenteral nutrition can result in electrolyte imbalances, including hypercalcemia (high levels of calcium in the blood).
The other laboratory results are within normal ranges and do not indicate a complication of total parenteral nutrition.
b) A BUN level of 16 mg/dL is within the normal range.
c) A serum potassium level of 4.6 mEq/L is within the normal range.
d) A WBC count of 8,000/mm³ is within the normal range.
A nurse is reinforcing teaching with a postpartum client about bathing her newborn.
Which of the following statements should the nurse include?
A. Wash your newborn's head under a stream of running water.
A) "Wash your newborn's head under a stream of running water": Washing the newborn's head under a stream of running water is not safe due to the risk of startling the baby or causing discomfort. Instead, the head should be gently washed using a damp cloth or sponge.
B. Bathe your newborn within 30 minutes after a feeding.
B) "Bathe your newborn within 30 minutes after a feeding": Bathing a newborn within 30 minutes after feeding is not advisable as it may cause discomfort or spitting up due to the baby's full stomach. It is better to wait for some time after feeding before bathing the baby.
C. Start the bath by washing the newborn's diaper area first.
C) "Start the bath by washing the newborn's diaper area first": Starting the bath by washing the newborn's diaper area first is not recommended. The face and head should be washed first to avoid spreading bacteria from the diaper area to other parts of the body.
D. The bath water should be 100 to 103 degrees Fahrenheit.
D) "The bath water should be 100 to 103 degrees Fahrenheit": This is the correct temperature range for a newborn's bath water. It is essential to ensure that the water is warm enough to be comfortable but not too hot, to avoid burns or discomfort. The temperature should be checked with a thermometer or the elbow to ensure it is safe for the baby.
Full Explanation
Answer: D
Rationale:
A) "Wash your newborn's head under a stream of running water": Washing the newborn's head under a stream of running water is not safe due to the risk of startling the baby or causing discomfort. Instead, the head should be gently washed using a damp cloth or sponge.
B) "Bathe your newborn within 30 minutes after a feeding": Bathing a newborn within 30 minutes after feeding is not advisable as it may cause discomfort or spitting up due to the baby's full stomach. It is better to wait for some time after feeding before bathing the baby.
C) "Start the bath by washing the newborn's diaper area first": Starting the bath by washing the newborn's diaper area first is not recommended. The face and head should be washed first to avoid spreading bacteria from the diaper area to other parts of the body.
D) "The bath water should be 100 to 103 degrees Fahrenheit": This is the correct temperature range for a newborn's bath water. It is essential to ensure that the water is warm enough to be comfortable but not too hot, to avoid burns or discomfort. The temperature should be checked with a thermometer or the elbow to ensure it is safe for the baby.
A nurse is assisting with an admission interview for a client who has schizophrenia. He tells the nurse that he is receiving special audible messages from the Central Intelligence Agency that no one else is able to hear. The nurse should identify that the client is having which of the following alterations in perception?
A. Derealization
Derealization (option a) refers to a subjective feeling of unreality or detachment from the environment. It involves a perception that the external world is strange, distorted, or unreal. This is not the primary alteration in perception described in the scenario.
B. Illusion
Illusion (option b) is a misinterpretation or misperception of a real sensory stimulus. It occurs when a person's perception of an actual stimulus is distorted or misunderstood. There is no indication of a misperception of a real stimulus in the scenario.
C. Hallucination
In the scenario described, the client's experience of receiving special audible messages from the Central Intelligence Agency that no one else can hear indicates a hallucination. Hallucinations are perceptual disturbances in which a person experiences sensory perceptions without any external stimuli. They can occur in any sensory modality, such as hearing (auditory hallucinations), seeing (visual hallucinations), smelling (olfactory hallucinations), tasting (gustatory hallucinations), or feeling (tactile hallucinations). In this case, the client is experiencing auditory hallucinations, as he is perceiving auditory stimuli (audible messages) that are not present in the external environment. Auditory hallucinations are most commonly associated with schizophrenia, although they can occur in other psychiatric disorders as well.
D. Depersonalization
Full Explanation
c. Hallucination
In the scenario described, the client's experience of receiving special audible messages from the Central Intelligence Agency that no one else can hear indicates a hallucination. Hallucinations are perceptual disturbances in which a person experiences sensory perceptions without any external stimuli. They can occur in any sensory modality, such as hearing (auditory hallucinations), seeing (visual hallucinations), smelling (olfactory hallucinations), tasting (gustatory hallucinations), or feeling (tactile hallucinations).
In this case, the client is experiencing auditory hallucinations, as he is perceiving auditory stimuli (audible messages) that are not present in the external environment. Auditory hallucinations are most commonly associated with schizophrenia, although they can occur in other psychiatric disorders as well.
Derealization (option a) refers to a subjective feeling of unreality or detachment from the environment. It involves a perception that the external world is strange, distorted, or unreal. This is not the primary alteration in perception described in the scenario.
Illusion (option b) is a misinterpretation or misperception of a real sensory stimulus. It occurs when a person's perception of an actual stimulus is distorted or misunderstood. There is no indication of a misperception of a real stimulus in the scenario.
Depersonalization (option d) is a subjective experience of being detached from one's own body, thoughts, or emotions. It involves a feeling of being outside of oneself or observing oneself from a distance. This is not the primary alteration in perception described in the scenario.
Therefore, the correct answer is c. Hallucination, as the client's experience of receiving special audible messages that no one else can hear represents an auditory hallucination.