A 90 y.o. nursing home resident with stage 2 Alzheimer’s disease is found alone and crying in the dining room. She says she lost her mother and doesn’t know what to do. Which response by the nurse will help calm the resident?

Correct Answer: C

Rationale: The correct answer is C: “Are you feeling frightened? I’m here and I will help you.” This response acknowledges the resident’s feelings, offers reassurance, and provides support, focusing on the resident's emotional needs rather than the accuracy of her statements. It shows empathy and validation of her feelings, which can help calm the resident and build trust. Choice A is incorrect because it dismisses the resident's feelings and reality, which can lead to increased distress and confusion. Choice B is incorrect as it doesn't address the resident's emotional state or offer immediate support. Choice D is incorrect as it focuses on correcting the resident's perception rather than providing emotional support, which may lead to further distress.

Correct Answer: D

Rationale: The correct answer is D: Fluid and electrolyte monitoring. In total parenteral nutrition (TPN), monitoring fluid and electrolyte balance is crucial to prevent complications like dehydration, electrolyte imbalances, and overload. Regular assessment ensures the patient's stability and prevents potential adverse effects. Option A (Evaluation of the peripheral venous site) is important but not essential compared to maintaining fluid and electrolyte balance. Option B (Confirmation that the tube is in the stomach) is irrelevant for a patient receiving TPN as it bypasses the GI tract. Option C (Assessment of the GI tract, including bowel sounds) is not necessary as TPN is given intravenously, bypassing the GI tract altogether.

Correct Answer: C

Rationale: The correct answer is C because flushing the central venous catheter with a heparinized solution before blood withdrawal is essential to maintain catheter patency and prevent clot formation. This step ensures the catheter is clear of any blockages, allowing for accurate blood sampling. Choice A is incorrect because assembling supplies should come after preparing the catheter. Choice B is incorrect as discarding blood before flushing the catheter may lead to inaccurate test results. Choice D is incorrect as replacing the catheter cap without flushing may lead to clot formation and catheter malfunction.

Correct Answer: B

Rationale: Step 1: Guillain-Barre Syndrome (GBS) is characterized by a rapid onset of weakness and tingling sensations in the legs. Step 2: Paresthesia refers to abnormal sensations like tingling or numbness, which is a common initial neurological symptom of GBS. Step 3: Absent tendon reflexes may occur in GBS due to muscle weakness but are not typically the initial symptom. Step 4: Dysrhythmias and transient hypertension are not typical symptoms of GBS and are not associated with its initial presentation. In summary, choice B is correct as paresthesia of the legs is a hallmark initial neurological symptom of Guillain-Barre Syndrome, while choices A, C, and D are incorrect as they do not align with the typical presentation of GBS.

Correct Answer: B

Rationale: The correct answer is B, Altered level of consciousness, because it is a critical assessment in determining Mr. Reyes's neurological status and overall well-being. Assessing for altered level of consciousness helps identify potential neurological issues, such as brain injury or stroke, which require immediate intervention. A: Decreased carotid pulses - This is related to cardiovascular assessment, not specific to Mr. Reyes's neurological status. C: Bleeding from oral cavity - While important to assess for, it is not directly related to Mr. Reyes's neurological status. D: Absence of deep tendon-reflexes - This is a specific neurological assessment, but altered level of consciousness takes priority in this scenario.