Which nursing intervention is most appropriate for a client with Alzheimer's disease who has frequent episodes of emotional lability?

Correct Answer: C

Rationale: The most appropriate nursing intervention for a client with Alzheimer's disease experiencing emotional lability is to reduce environmental stimuli to redirect attention (Choice C). This helps to minimize triggers that can exacerbate emotional outbursts. By creating a calm and less stimulating environment, the client's emotional responses may be more stable. Attempting humor (Choice A) may not be effective as it could be misinterpreted or escalate emotions. Exploring reasons for the client's mood (Choice B) may not be feasible due to cognitive impairments. Using logic (Choice D) may not be effective as clients with Alzheimer's may have difficulty processing logical reasoning.

Correct Answer: C

Rationale: The correct answer is C: Orientation. The nurse is assessing the client's awareness of time, place, and person, which are key components of orientation. By asking about the day, date, month, year, and location, the nurse is evaluating the client's cognitive function and ability to understand their surroundings. Confabulation (A) is the spontaneous creation of false memories, not relevant in this scenario. Delirium (B) is an acute state of confusion with rapid onset, not a specific assessment like orientation. Perseveration (D) is the repetition of a particular response, also not relevant to the assessment of orientation.

Correct Answer: B

Rationale: The correct answer is B: Development of autonomy within the family. Differentiation in family systems theory refers to the ability of individuals to maintain their own sense of self while being emotionally connected to family members. This process involves developing autonomy, where family members can express their own thoughts, feelings, and values independently. This is crucial for healthy family dynamics and individual growth. Incorrect Options: A: Cooperative action among members of the family - While cooperation is important in family systems, it does not specifically refer to the process of differentiation. C: Incongruent messages wherein the recipient is a victim - This option describes communication issues rather than differentiation. D: Maintenance of system continuity or equilibrium - This option refers to the overall stability of the family system, which is different from the process of differentiation.

Correct Answer: A

Rationale: The correct answer is A because it dismisses the client's feelings and concerns by invalidating them with a generic reassurance. It fails to acknowledge the client's emotions and can come across as patronizing. Choice B acknowledges the client's emotional state, while choice C observes a behavior without judgment. Choice D addresses the client's thoughts without dismissing them, making it a more empathetic response.

Correct Answer: A

Rationale: Step-by-step rationale: 1. The nurse holds a Western worldview, which may not align with the cultural beliefs of Hispanic patients. 2. Using pamphlets may not effectively communicate information in a culturally sensitive manner. 3. Short and concise groups may be perceived as rushed or lacking in depth. 4. Patients may feel the nurse was uncaring due to the mismatch in cultural understanding and communication style. Summary: The correct answer is A because cultural differences and communication styles can lead to patients feeling uncared for despite the nurse's intentions. Choices B, C, and D are incorrect because effectiveness, efficiency, and respect can be compromised when cultural considerations are not adequately addressed.