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Questions 163

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Question 1 of 5

The nurse is caring for a client with mild Alzheimer disease who is agitated after eating breakfast. The client states, 'I am hungry. You did not feed me.' Which of the following actions should the nurse take?

Correct Answer: C

Rationale: For an Alzheimer client with agitation and false hunger claims, offering a snack before lunch calms the client without overfeeding. Finger foods or extra meals may not address agitation, and a dietician evaluation is less immediate.

Question 2 of 5

The nurse is reviewing the medical record of a 4-year-old client with failure to thrive. Which of the following risk factors likely contribute to the client's condition? Select all that apply.

Correct Answer: B,C,E

Rationale: FTT risk factors include parental incarceration causing family stress, a history of anorexia nervosa affecting feeding practices, and food insecurity . Being the youngest or a working parent are not direct risks.

Question 3 of 5

A client with Alzheimer disease is admitted to the hospital. The client's adult child says to the nurse, 'I really want to continue caring for my mother at home, but she has become agitated and restless at night. I am awake most of the night, feel exhausted, and do not know what to do.' What is the best response by the nurse?

Correct Answer: B

Rationale: Referring to a social worker provides access to resources like respite care or home support, addressing the caregiver's exhaustion. Limiting naps or medication may help but are narrow, and suggesting a facility dismisses the caregiver's wishes.

Question 4 of 5

A nurse in a school health clinic is reinforcing teaching for the parent of a young client with pediculosis capitis. Which statement by the parent indicates understanding of the teaching?

Correct Answer: A

Rationale: Laundering clothing, sheets, and towels in hot water effectively kills lice and nits, indicating understanding. Dishwashing utensils is irrelevant, spraying insecticide is unnecessary, and discarding toys is excessive if they can be sealed or washed.

Question 5 of 5

The nurse is caring for a client who had a right modified radical mastectomy 4 hours ago. The nurse should place the client in the

Correct Answer: C

Rationale: Semi-Fowler position with the right arm elevated promotes drainage and reduces edema post-mastectomy. High Fowler may strain the incision, and supine without elevation (B,
D) increases edema risk.

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