During the initial home visit, a nurse is discussing the care of a client newly diagnosed with Alzheimer's disease with family members. Which of these interventions would be most helpful at this time?

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Question 1 of 5

During the initial home visit, a nurse is discussing the care of a client newly diagnosed with Alzheimer's disease with family members. Which of these interventions would be most helpful at this time?

Correct Answer: D

Rationale: Suggesting communication strategies is most helpful early in Alzheimer's. It aids family coping with cognitive decline, per disease stage. Relaxation , exercise , and nutrition are secondary. D supports interaction, making it key.

Question 2 of 5

A client experienced the loss of a spouse 12 months ago. Today the client reveals feelings of anger and hopelessness to the nurse. Which initial response by the nurse would be most appropriate?

Correct Answer: B

Rationale: Tell me more about how you are feeling now' is the most appropriate initial response. It invites the client to elaborate, facilitating therapeutic communication and assessing grief progression, per nursing principles. Condemning anger dismisses emotions, predicting resolution offers false reassurance, and redirecting to family avoids engagement. After 12 months, anger and hopelessness may indicate complicated grief, needing exploration. B builds trust, encourages expression, and informs care, making it the best choice.

Question 3 of 5

While assessing a client with a casted right ankle and foot, the nurse notes the toes are more edematous than they were several hours ago and are cool to touch despite elevation of the foot above the level of the heart. Which action should the nurse take first?

Correct Answer: A

Rationale: Notifying the provider immediately is first. Increased edema and coolness despite elevation suggest vascular compromise (e.g., compartment syndrome), needing urgent evaluation, per protocol. More assessments delay, documentation is secondary, and heat worsens swelling. A ensures timely intervention, making it the initial step.

Question 4 of 5

A client who had a laparoscopic appendectomy 2 days ago reports pain at a level of 8 out of 10 at the incision site. Which action should the nurse take first?

Correct Answer: A

Rationale: Administering the prescribed analgesic is first for pain at 8/10 post-appendectomy. Severe pain needs rapid relief, per protocol, assuming PRN orders. Assessing , notifying , or breathing follow. A prioritizes comfort, making it the initial step.

Question 5 of 5

A client with a central venous catheter reports pain at the insertion site. Which action should the nurse take first?

Correct Answer: B

Rationale: Assessing the site for redness or swelling is first for pain at a CVC site. It identifies infection or thrombosis, guiding care, per nursing process. Flushing , medicating , or notifying follow assessment. B ensures accurate intervention, making it priority.

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