The home care nurse assessed a client with a history of dementia who had a herniorrhaphy at an ambulatory surgical center the previous day. The client lives in a senior living facility. The client thinks he is in the army and that it is 1945. The nurse should:

Correct Answer: A

Rationale: The correct answer is A: Reorient the client to the current time and place. The nurse should reorient the client to prevent distress and promote safety. This approach helps the client feel more secure and may reduce confusion. Choice B is incorrect because the nurse should address the client's needs first. Choice C is not enough on its own as the nurse needs to actively assist the client. Choice D is incorrect as action is needed in this situation to support the client.

Correct Answer: A

Rationale: The correct answer is A. The nurse should provide education and information about the medical diagnosis, delirium secondary to anticholinergic medication toxicity. This is important because it helps the family understand the condition, its causes, symptoms, and treatment. By educating the family, they can better support the patient and be involved in the care plan. Choice B is incorrect because it provides false reassurance without addressing the underlying issue or providing necessary information. Choice C is incorrect because suggesting nursing home placement is premature and not based on the patient's current condition or needs. Therefore, the best approach is to choose option A to empower the family with knowledge and understanding to better assist the patient.

Correct Answer: B

Rationale: The correct answer is B: Primary sleep disorders. These disorders directly affect the sleep-wake cycle or timing mechanisms of the body. Sleep apnea (A) is a specific disorder characterized by pauses in breathing during sleep, not a general category. Tertiary sleep disorders (C) are not a recognized classification; the primary and secondary are the main categories. "None of the above" (D) is incorrect as primary sleep disorders are indeed related to abnormal functioning of the sleep-wake cycle.

Correct Answer: A

Rationale: The correct answer is A because patients with bulimia nervosa are at risk for electrolyte imbalances and cardiac issues due to purging behaviors. Monitoring electrolyte levels and cardiac function is crucial for early detection and intervention. Option B is incorrect as it focuses on behaviors rather than potential medical complications. Option C is less critical than monitoring electrolytes and cardiac function. Option D, although important, is not as immediately critical as monitoring electrolyte levels and cardiac function in this context.

Correct Answer: B

Rationale: The correct answer is B: Provide a structured environment with clear expectations around eating behaviors. This is important in managing bulimia nervosa as it helps establish a routine, promotes healthy eating habits, and prevents binge-purge cycles. It provides consistency and boundaries, reducing the likelihood of impulsive behaviors. Incorrect choices: A: Allowing the patient to choose their preferred food options can enable unhealthy eating patterns and reinforce disordered behaviors. C: Monitoring for weight gain and decreasing calorie intake can worsen the patient's condition and perpetuate their obsession with weight and food. D: Encouraging regular exercise routines may exacerbate the patient's unhealthy relationship with food and body image, leading to excessive exercising or compensatory behaviors.