Uworld mental health nursing
The nurse is providing care for a client with Alzheimer disease who often becomes angry and agitated 20 minutes or more
... [Show More] after eating. The client accuses the nurse of not providing food, saying, "I'm hungry. You didn't feed me." The nurse should take which action?
Unordered Options Ordered Response
1. Give the client gentle reminders that the client has already eaten
2. Say that the client can have a snack in a couple of hours
3. Serve the client half of the meal initially and offer the other half later
4. Take a picture of the client having a meal and show it when the client becomes upset
Explanation
Most clients with Alzheimer disease experience eating and nutritional problems throughout the course of their disease. During the earlier stages, it is common for clients to forget that they have eaten recently. The best approach is for caregivers to give clients something to eat when they say they are hungry. Smaller meals throughout the day, along with low-calorie snacks, are effective strategies for clients who forget that they have eaten.
(Option 1) Reality orientation has been recommended in the past as a way to deal with confusion (eg, dementia, Alzheimer disease), but research has shown that it may cause anxiety and distress. Validation therapy is a newer and more therapeutic approach that validates and accepts the client's reality.
(Option 2) Offering to provide a snack later does not address the client's stated need to eat now. Delay in giving food will only further increase the client's anger and frustration.
(Option 4) Showing a picture of the client having a meal is confrontational and will have no meaning to the client.
Educational objective:
Clients with Alzheimer disease experience eating and nutritional problems throughout the course of the disease. During the earlier stages, it is common for them to forget that they have eaten recently. The best approach is for caregivers to give clients something to eat when they say they are hungry.
Test Id: 52050973
Question Id: 33389 (729561)
The nurse cares for a client who had an abdominal aortic aneurysm repair 6 hours ago. Which assessment would require immediate follow-up?
Unordered Options Ordered Response
1. Abdomen is soft, nondistended, and tender to touch
2. Blood pressure is 96/66 mm Hg and apical pulse is 112/min
3. Client rates pain as 4 on a scale of 0-10
4. Green bile is draining from the nasogastric tube
Explanation
Abdominal aortic aneurysms are surgically repaired when they measure about 6 cm or are causing symptoms. Repair can be done via femoral percutaneous placement of a stent graft (endovascular aneurysm repair) or via an open surgical incision of the aneurysm with synthetic graft placement. The client must be monitored postoperatively for graft leakage and hemodynamic stability. Adequate blood pressure is necessary to maintain graft patency, and prolonged hypotension can lead to the formation of graft thrombosis. Signs of graft leakage include a decreasing blood pressure and increasing pulse rate.
(Option 1) Following surgery, the client will experience abdominal tenderness. The abdomen should remain soft and nondistended. A rigid, distended abdomen would indicate possible blood (graft leakage) in the cavity.
(Option 3) Pain is an expected finding following abdominal surgery. However, increasing pain that is not relieved by medication can indicate possible graft leakage and should be investigated.
(Option 4) During abdominal surgeries, it is customary to insert a nasogastric tube that is left in place during the immediate postoperative period. Green bile-colored drainage would be expected. Bloody drainage would cause concern.
Educational objective:
Following repair of an abdominal aortic aneurysm, hemodynamic stability is a priority. Prolonged hypotension can lead to graft thrombosis. A falling blood pressure and rising pulse rate can also signify graft leakage. [Show Less]