The nurse makes a home visit to a family caring for a client with Alzheimer's disease. The client's wife tells the nurse that she hasn't been out of the house for more than 2 weeks because her sister has been unable to help her care for the client. Which nursing diagnosis would the nurse identify as the priority?

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Question 1 of 5

The nurse makes a home visit to a family caring for a client with Alzheimer's disease. The client's wife tells the nurse that she hasn't been out of the house for more than 2 weeks because her sister has been unable to help her care for the client. Which nursing diagnosis would the nurse identify as the priority?

Correct Answer: C

Rationale: The correct answer is C: Caregiver Role Strain related to social isolation. The priority nursing diagnosis addresses the wife's current state of distress due to social isolation, which can impact her ability to provide care for the client. This diagnosis directly addresses her feelings of being overwhelmed and unable to fulfill her caregiving role effectively. In contrast, option A focuses on family coping, which is secondary to the wife's immediate need for support. Option B is not as relevant since it does not address the wife's emotional and psychological stress. Option D refers to the client's emotional state rather than the wife's, making it less of a priority in this scenario.

Question 2 of 5

A nurse is assessing a client brought to the hospital psychiatric emergency services by a law enforcement officer. The client has disorganized, incoherent speech with loose associations and religious content. You should recognize the signs and symptoms as being consistent with which of the following?

Correct Answer: B

Rationale: The correct answer is B: Schizophrenia. The client's symptoms of disorganized, incoherent speech with loose associations and religious content are classic features of schizophrenia, specifically the positive symptoms. Schizophrenia is a severe mental disorder characterized by disturbances in thinking, emotions, and behavior. It typically presents in late adolescence or early adulthood. On the other hand, the other choices are incorrect because Alzheimer's disease primarily affects memory and cognitive function, substance intoxication would manifest with different symptoms depending on the substance, and depression typically presents with persistent feelings of sadness, hopelessness, and loss of interest in daily activities.

Question 3 of 5

April, a 10-year-old admitted to inpatient pediatric care, has been getting more and more wound up and is losing self-control in the day room. Time-out does not appear to be an effective tool for April to engage in self-reflection. April's mother admits to putting her in time-out up to 20 times a day. The nurse recognizes that:

Correct Answer: B

Rationale: The correct answer is B because the scenario indicates that time-out is no longer effective for April. The fact that April's mother puts her in time-out up to 20 times a day suggests overuse, leading to desensitization. This renders time-out ineffective as a therapeutic tool. April's increasing agitation and lack of self-control despite time-outs indicate the need for a different approach. Choices A and C are incorrect because they assume time-out is still effective, which contradicts the scenario. Choice D is incorrect as seclusion and restraint should only be considered as a last resort due to ethical and safety concerns.

Question 4 of 5

The impulse control spectrum can begin in childhood and continue on into adulthood, often morphing into criminal behaviors. Working with patients diagnosed with these disorders, the best examples of expressed emotion by the nursing staff are:

Correct Answer: A

Rationale: The correct answer is A: Low to prevent emotional reactions. When working with patients with impulse control disorders, it is crucial for nursing staff to maintain low expressed emotion levels to prevent triggering emotional reactions in the patients. High emotional expression can exacerbate the patients' symptoms and lead to escalated behaviors. Matching the patient's emotions (B) can also be risky as it may inadvertently validate or reinforce maladaptive behaviors. Being flat (C) without any emotional output can be perceived as cold and uncaring, hindering the therapeutic relationship. High expression (D) may overwhelm the patient and hinder therapeutic progress. Therefore, maintaining low emotional reactions is the most effective approach to support patients with impulse control disorders.

Question 5 of 5

Which factor isn't likely to attract a patient to complementary and alternative medicine?

Correct Answer: A

Rationale: The correct answer is A because the statement that complementary and alternative medicine is always less expensive than conventional medical treatment is not true. Cost is often a significant factor in healthcare decisions, but it is not the only factor that attracts patients to complementary and alternative medicine. Patients may be drawn to these practices due to a desire for more personalized care (B), a perception of lower risk compared to pharmaceuticals (C), or dissatisfaction with the effectiveness of traditional medicine (D). However, cost alone is not a primary factor in choosing complementary and alternative medicine.

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