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A Nurse In An Acute Care Facility Is Assisting With The Admission Of An Older Adult Client Who Has Late
Stage Alzheimer's Disease. The Nurse Notes That The Client's Partner Appears Exhausted. He States That
He Is Finding It More And More Difficult To Care For His Partner. Which Of The Following Actions Should
The Nurse Take First?
ANSWER: Ask The Partner To Talk About His Difficulties In Caring For The Client.
The First Action The Nurse Should Take, Using The Nursing Process Priority Framework, Is To Collect
Data Regarding The Partner's Ability To Take Care Of The Client.
A Nurse Is Collecting Data From A Client Who Is Taking Bupropion. Which Of The Following Findings
Indicates The Medications Is Effective?
ANSWER: Decrease In Urge To Smoke
Bupropion Is An Antidepressant That Is Also Used For Smoking Cessation.
A Nurse Is Evaluating The Outcome For A Client Who Has Depression Following The Death Of His Wife 3
Months Ago. Which Of The Following Client Statements Indicates A Need For Further Intervention?
ANSWER: "I Just Don't Feel Like Eating Because I Never Like To Eat Alone."
At Risk For Malnutrition And Injury.
A Nurse In A Long-Term Care Setting Is Caring For A Client Who Has Alzheimer's Disease. The Client
States, "I Just Came Back From A Hard Day's Work In My Office." The Nurse Should Identify This
Statement Is An Example Of Which Of The Following Coping Mechanisms?
ANSWER: Confabulation
Confabulation Is The Creation Of Information Which Is Untrue To Fill In Gaps In Memory And To Protect
Self-Esteem In Clients Who Have Dementia.
, A Nurse Is Planning Care For A New Client. Which Of The Following Actions Should The Nurse Plan To
Take In Order To Use The Technique Of Presence To Establish The Nurse- Client Relationship?
ANSWER: Use Active Listening When With The Client.
The Nurse Should Use Active Listening To Establish Presence With The Client. Presence Involves Eye
Contact, Body Language, Voice Tone, Listening, And Reflection To Convay Openness And Understanding.
A Nurse Is Assessing A Client In The Emergency Department Who Drank Alcohol While Taking Disulfiram.
The Client States, "The Nurse Told Me Not To Drink When Taking The Medication. I Am Just A Social
Drinker. I Didn't Realize That Having Just One Drink With My Friends Would Cause Such A Problem."
Which Of The Following Defense Mechanisms Is The Client Demonstrating?
ANSWER: Rationalization
The Client Is Demonstrating Rationalization When He Creates Reasonable And Acceptable Explanations
For Unacceptable Behavior. The Client Is Using Rationalization Asa Defense Mechanisms To Justify Why
He Had Just One Drink. Even Though The Nurse Told Him Not To Drink Alcohol.
A Nurse Is Caring For A Group Of Older Adult Clients. Which Of The Following Client Findings Indicates
Delirium?
ANSWER: A Client Asks When Family Members Will Be Arriving After Visiting 1 Hr Earlier.
Delirium Is Characterized By A Change In Cognition That Occurs Over A Short Period Of Time. It Always
Results From Secondary Physiological Condition, ( Infection, Surgery, Prolonged Hospitalization, Hypoxia,
Fever, Medication) And Is A Transient Disorder. Although Delirium Can Occur At Any Age, It Is More
Common In Older Adults. It Frequently Progresses In The Evening Hours And Is Sometimes Called
"Sundown Syndrome"
A Nurse Is Collecting Data From A Client Newly Admitted For Anorexia Nervousa. Which Of The
Following Findings Should The Nurse Expect?
ANSWER: Amenorrhea
The Nurse Should Expect The Client To Report Amenorrhea Due To Low Body Weight.