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: Option C, "Are you feeling frightened? I'm here and I will help you," is the most appropriate response to help calm the resident. The resident is experiencing confusion and distress, likely due to her Alzheimer's disease. Invalidating her feelings by reminding her of the reality may lead to more confusion and distress. Instead, acknowledging the resident's emotions, offering support, and reassuring her of your presence can help calm her down and provide comfort in the moment. It is important to provide emotional support and reassurance to individuals with Alzheimer's disease, rather than focusing on correcting their statements or reminding them of reality.

Correct Answer: B

Rationale: Positioning the patient on their side is a critical nursing action that prepares a patient for a lumbar puncture. This position is usually used during the procedure to allow easier access to the lumbar region. Placing the patient on their side helps provide better visualization of the spinal landmarks and facilitates the correct positioning of the needle for the lumbar puncture. This position also helps minimize the risk of complications and ensures the safety and comfort of the patient during the procedure. Administering enemas until clear, removing all metal jewelry, and removing the patient's dentures are not specifically associated with preparing a patient for a lumbar puncture.

Correct Answer: C

Rationale: Trigeminal neuralgia is a condition characterized by sudden and severe facial pain caused by irritation or damage to the trigeminal nerve. Trigeminal neuralgia pain is often triggered by certain activities that stimulate the nerve, such as eating, talking, or brushing teeth. The act of chewing and ingesting food can put pressure on the trigeminal nerve, leading to increased pain for individuals suffering from trigeminal neuralgia. Therefore, eating is most likely to aggravate the pain in a 19-year-old student with trigeminal neuralgia.

Correct Answer: C

Rationale: Trihexyphenidyl is an anticholinergic medication commonly used to treat symptoms of Parkinson's disease. Anticholinergic drugs work by blocking the action of acetylcholine, a neurotransmitter in the nervous system. One common side effect of anticholinergic medications like trihexyphenidyl is dryness of the mouth (xerostomia). This occurs because the drug interferes with the normal functioning of the salivary glands, leading to reduced saliva production. Excessive salivation (choice A) is unlikely due to the drying effect of the medication. Bradycardia (choice B) is not typically associated with trihexyphenidyl use. Constipation (choice D) is another common adverse effect of anticholinergic medications, but dryness of the mouth is more closely related in this scenario.

Correct Answer: A

Rationale: A relaxed face during conversation is not typically indicative of hearing loss. In fact, individuals with hearing loss may exhibit signs such as speaking loudly (Choice B), turning toward the person speaking (Choice C), and feeling withdrawn (Choice D) due to difficulty in hearing and understanding conversations. The act of speaking loudly may be an attempt to compensate for the perceived hearing loss, while turning toward the speaker is a common strategy to better hear and lip-read. Withdrawal can result from the frustration and isolation caused by the inability to fully engage in conversations. Ultimately, a relaxed face during conversation is less likely to be a red flag for hearing loss compared to the other choices provided.