A daughter brings her mother, who has Alzheimer's disease, to the clinic. The client has been taking a cholinesterase inhibitor medication for 1 month. When assessing the client, the nurse would be alert for the possibility of which side effect?

Correct Answer: A

Rationale: The correct answer is A: Gastrointestinal distress. Cholinesterase inhibitors, commonly used to treat Alzheimer's disease, can cause gastrointestinal side effects such as nausea, vomiting, diarrhea, and loss of appetite. This occurs due to the increased cholinergic activity in the gastrointestinal tract. Monitoring for gastrointestinal distress is crucial to ensure the client's well-being and may require dose adjustments or additional interventions. Incorrect choices: B: Mild headache - Cholinesterase inhibitors are not typically associated with causing headaches as a side effect. C: Muscle tics - Cholinesterase inhibitors do not typically cause muscle tics as a side effect. D: Blurred vision - While blurred vision can be a side effect of some medications, it is not commonly associated with cholinesterase inhibitors used in Alzheimer's disease treatment.

Correct Answer: C

Rationale: First, the nurse should prioritize safety and infection control by donning sterile gloves to prevent contamination during the dressing change. This is essential to maintain asepsis and prevent wound infection. Applying skin preparation (A) can wait until after the gloves are on. Normal saline (B) is typically used during wound cleaning but is not the first step. Determining pain level (D) is important but not the immediate priority for this procedure.

Correct Answer: B

Rationale: The correct answer is B: Cerebellum maturation. The cerebellum is responsible for emotional regulation and cognitive functions. As it matures during adolescence, individuals gain better emotional and behavioral control. Limited executive function (A) would hinder rather than improve control. Cerebral stasis and hormonal changes (C) do not directly contribute to emotional regulation. A slight reduction in brain volume (D) would not necessarily lead to increased emotional and behavioral control.

Correct Answer: C

Rationale: The correct answer is C: When setting limits, be specific and outline consequences. This is the most appropriate advice for working with patients with oppositional defiant disorder. By being specific and outlining consequences, the nurse establishes clear boundaries and expectations. This approach helps the patient understand the consequences of their actions and promotes accountability. Explanation of incorrect choices: A: Using a loud firm tone can escalate the situation and may trigger defensiveness in patients with oppositional defiant disorder. B: Using language beyond the patient's education level can lead to misunderstandings and hinder effective communication. D: An aggressive body language can be perceived as threatening and may worsen the patient's behavior, rather than gaining respect.

Correct Answer: C

Rationale: The correct answer is C because integrative care focuses on treating the whole person, including their body, mind, and spirit. This approach recognizes the interconnectedness of these aspects in promoting overall health and well-being. Choice A is incorrect as it only mentions the physician's diagnosis and patient's response, neglecting the holistic approach of integrative care. Choice B is incorrect as it specifically mentions the nurse's ideas without addressing the broader perspective of integrating body, mind, and spirit. Choice D is incorrect as it prioritizes the diagnosis over addressing the spiritual aspect of care, which is essential in integrative medicine.