Question

A client diagnosed with Alzheimer's Disorder has impairments of memory and judgement and is incapable of performing activities of daily living. Which nursing intervention should take priority?

Answer 1

Correct Answers:

Assist the client with bathing and toileting.

Rationale :

🔵 Clients with Alzheimer’s Disease in moderate to severe stages experience significant impairments in memory, judgment, and self-care ability.

🔵 The highest nursing priority is to support basic needs and physical safety, including hygiene and toileting assistance.

🔵 Failure to address these needs can result in skin breakdown, infection, and decreased dignity.

🔵 Cognitive interventions like labeling or bulletin boards are helpful but are secondary to maintaining basic physiological functioning.

🔵 ADLs are part of Maslow’s physiological level, making them essential for survival and comfort.

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Answer 2

Correct Answers:

Confabulation

Rationale :

🔴 Confabulation refers to the unconscious fabrication of events to fill memory gaps, common in neurocognitive disorders like Alzheimer's.

🔴 The client is not intentionally lying but creating a false but plausible memory to maintain self-esteem or reduce anxiety.

🔴 This behavior occurs as a result of impaired memory function, often involving recent events.

🔴 Confabulation differs from delusion because it is not fixed or psychotic in origin.

🔴 It is a coping mechanism used by individuals with memory loss to appear oriented.

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Answer 3

Correct Answers:

"You feel that your mother does not want you to come back home?"

Rationale :

🟡 This response demonstrates therapeutic communication by using restating, which encourages the client to explore their feelings further.

🟡 It reflects the client's emotions back to them in a nonjudgmental and supportive manner.

🟡 The goal is to validate the client’s concerns and promote an open dialogue.

🟡 Therapeutic responses avoid advice-giving and instead facilitate self-awareness and trust.

🟡 This approach is foundational in mental health nursing practice for building rapport.

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Answer 4

Correct Answers:

Asking the client, "Why?"

Rationale :

🟣 The word "Why?" can feel confrontational or judgmental, and may cause the client to become defensive.

🟣 Therapeutic communication should be non-threatening and client-centered, promoting trust.

🟣 Effective techniques include restating, active listening, silence, and summarizing, which encourage dialogue.

🟣 “Why” questions often shift focus away from emotions and toward rationalizing behavior, which is not therapeutic.

🟣 Avoiding this type of questioning supports a safe therapeutic environment.

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Answer 5

Correct Answers:

is pacing around the milieu.

Rationale :

🔶 Pacing is a behavioral cue that suggests agitation and escalating aggression, especially when combined with clenched fists.

🔶 It is a sign of rising internal tension, and the nurse must act to de-escalate before aggression escalates to violence.

🔶 Recognizing early signs allows for timely intervention and safety measures.

🔶 Clients with a history of violence require close observation for nonverbal aggression markers.

🔶 Intervening during this stage may prevent entry into the crisis phase of aggression.

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Answer 6

Correct Answers:

Increased restlessness

Rationale :

🔷 Restlessness is a potential early sign of hypoxia, hemorrhage, or pain, especially in post-op clients.

🔷 It often precedes other vital sign changes, making it a critical early clinical indicator.

🔷 The nurse must assess for oxygenation, bleeding, or neurologic complications.

🔷 While vital signs and bowel sounds are part of routine post-op monitoring, behavioral changes may indicate deterioration.

🔷 Prompt action ensures early detection of post-op complications.

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Answer 7

Correct Answers:

"Psychological factors like excessive stress have been found to affect medical conditions"

Rationale :

🟠 This response provides a professional, factual rationale for the psychosocial questions being asked.

🟠 It helps the client understand the mind-body connection, which is well-documented in health outcomes.

🟠 Education can reduce defensiveness or stigma around discussing mental health.

🟠 The response avoids confrontation and maintains a therapeutic tone.

🟠 It reinforces that comprehensive assessment includes both physical and emotional factors.

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Answer 8

Correct Answers:

The client smokes one pack of cigarettes per day.

Rationale :

🔺 Clients with vascular neurocognitive disorder (NCD) have a history of cerebrovascular compromise, and smoking is a major risk factor for further deterioration.

🔺 Nicotine contributes to hypertension, stroke, and vascular injury, worsening NCD symptoms.

🔺 Ongoing smoking behavior poses a direct threat to cognitive and cardiovascular health.

🔺 While caregiver support is important, this behavior has the most immediate clinical risk.

🔺 The nurse should prioritize education and intervention related to smoking cessation.

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Answer 9

Correct Answers:

Pulling out their hair

Rationale :

🟤 Trichotillomania is an impulse control disorder characterized by repetitive hair pulling, often as a way to reduce anxiety or stress.

🟤 This behavior provides temporary relief but is followed by distress or shame.

🟤 It can lead to visible hair loss, skin irritation, or infection.

🟤 It often occurs alongside other anxiety or obsessive-compulsive disorders.

🟤 Treatment includes habit reversal training and behavioral therapy.

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Answer 10

Correct Answers:

demonstrated healthy coping mechanisms that decreased anxiety.

Rationale :

💎 Recovery from bulimia nervosa includes the development of non-food-related coping skills to manage anxiety.

💎 The ability to recognize triggers and respond with healthier behaviors is a clear sign of progress.

💎 Focusing on healthy coping reflects insight and behavioral change, which are key in long-term management.

💎 Successful therapy outcomes are based not only on weight but also on emotional regulation and decreased compulsive behaviors.

💎 This approach aligns with cognitive-behavioral therapy goals for eating disorders.

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QLexNursing

1 :
A client diagnosed with Alzheimer's Disorder has impairments of memory and judgement and is incapable of performing activities of daily living. Which nursing intervention should take priority?

2 :
A client is diagnosed with Alzheimer's disease. When asked about the previous evening, the client describes a wonderful evening spent on a cruise. Which symptom is the client exhibiting?

3 :
A client tells the nurse, "l feel bad because my mother does not want me to return home after I leave the hospital .Which nursing response is therapeutic?

4 :
A nurse working in a mental health unit reviews therapeutic and non-therapeutic communication techniques with a student nurse. All of the following are therapeutic communication techniques except:

5 :
The nurse is assessing an inpatient client with a known history of violence. The client suddenly displays clenched fists. What additional behavior by the client would suggest that the aggression is escalating? The client:

6 :
The nurse is assessing the status of a post-operative client in the PACU. The nurse should be most concerned with which assessment finding?

7 :
During a client intake assessment, the nurse asks both physiological and psychosocial questions. The client angrily responds, "I'm here for my heart, not my head problems." What is the nurse's best response?

8 :
A client diagnosed with vascular neurocognitive disorder (NCD) is discharged to home under the care of his wife. Which information should cause the nurse to question the client's safety?

9 :
A client is diagnosed with Trichotillomania. The client has relieved the anxiety over the years by doing what type of behavior?

10 :
A client diagnosed with bulimia nervosa has been attending a mental health clinic for several months. Which factor should a nurse identify as an appropriate indicator of a positive client behavioral change? The client:

QLexNursing

1 : A client diagnosed with Alzheimer's Disorder has impairments of memory and judgement and is incapable of performing activities of daily living. Which nursing intervention should take priority?

2 : A client is diagnosed with Alzheimer's disease. When asked about the previous evening, the client describes a wonderful evening spent on a cruise. Which symptom is the client exhibiting?

3 : A client tells the nurse, "l feel bad because my mother does not want me to return home after I leave the hospital .Which nursing response is therapeutic?

4 : A nurse working in a mental health unit reviews therapeutic and non-therapeutic communication techniques with a student nurse. All of the following are therapeutic communication techniques except:

5 : The nurse is assessing an inpatient client with a known history of violence. The client suddenly displays clenched fists. What additional behavior by the client would suggest that the aggression is escalating? The client:

6 : The nurse is assessing the status of a post-operative client in the PACU. The nurse should be most concerned with which assessment finding?

7 : During a client intake assessment, the nurse asks both physiological and psychosocial questions. The client angrily responds, "I'm here for my heart, not my head problems." What is the nurse's best response?

8 : A client diagnosed with vascular neurocognitive disorder (NCD) is discharged to home under the care of his wife. Which information should cause the nurse to question the client's safety?

9 : A client is diagnosed with Trichotillomania. The client has relieved the anxiety over the years by doing what type of behavior?

10 : A client diagnosed with bulimia nervosa has been attending a mental health clinic for several months. Which factor should a nurse identify as an appropriate indicator of a positive client behavioral change? The client:

1 :
A client diagnosed with Alzheimer's Disorder has impairments of memory and judgement and is incapable of performing activities of daily living. Which nursing intervention should take priority?

2 :
A client is diagnosed with Alzheimer's disease. When asked about the previous evening, the client describes a wonderful evening spent on a cruise. Which symptom is the client exhibiting?

3 :
A client tells the nurse, "l feel bad because my mother does not want me to return home after I leave the hospital .Which nursing response is therapeutic?

4 :
A nurse working in a mental health unit reviews therapeutic and non-therapeutic communication techniques with a student nurse. All of the following are therapeutic communication techniques except:

5 :
The nurse is assessing an inpatient client with a known history of violence. The client suddenly displays clenched fists. What additional behavior by the client would suggest that the aggression is escalating? The client:

6 :
The nurse is assessing the status of a post-operative client in the PACU. The nurse should be most concerned with which assessment finding?

7 :
During a client intake assessment, the nurse asks both physiological and psychosocial questions. The client angrily responds, "I'm here for my heart, not my head problems." What is the nurse's best response?

8 :
A client diagnosed with vascular neurocognitive disorder (NCD) is discharged to home under the care of his wife. Which information should cause the nurse to question the client's safety?

9 :
A client is diagnosed with Trichotillomania. The client has relieved the anxiety over the years by doing what type of behavior?

10 :
A client diagnosed with bulimia nervosa has been attending a mental health clinic for several months. Which factor should a nurse identify as an appropriate indicator of a positive client behavioral change? The client: