Version 3 PQs Flashcards
A client with stage 3 Alzheimer’s disease is living with his son and daughter-inlaw. The visiting nurse is educating the family about the progression of the illness,
including “sundown syndrome,” and is assisting with care planning and comfort
measures. Which statement by the daughter-in-law reflects that the teaching has
been effective?
“We will have locks placed at the top of all the outside doors.”
Rationale:
Placing locks at the top of the doors is an important safety intervention. The term
“sundown syndrome” refers to behaviors that become more pronounced in the
evening. Clients with late stage dementia are prone to wandering, especially at
night.
A student nurse working as an aide in a memory care facility asks the charge nurse
if there is a neurobiological basis for the deterioration in cognitive function in
Alzheimer’s disease. Which explanation by the nurse is correct regarding the
etiology of neurocognitive decline?
“Decreases in neurotransmitters affect parts of the brain responsible for memory.”
Rationale:
Neurocognitive decline is associated with changes in neurotransmitter
concentration. Alzheimer’s disease has been linked with a decrease in the
production and function of acetylcholine (ACh). Alzheimer’s disease affects an
area of the brain called the nucleus basalis, which contains cholinergic neurons.
These neurons provide ACh to areas of the brain responsible for memory and
learning.
A client with long-term alcohol addiction is admitted to the emergency department.
Which medications should the nurse anticipate the healthcare provider will
prescribe for this client?
Diazepam.
Multivitamins.
Thiamine (vitamin B1).
Rationale:
Alcohol withdrawal delirium usually peaks 48-72 hours since last consumption of
alcohol. The diazepam has sedative and anticonvulsant properties. Thiamine and
multivitamins are usually given to help with nutritional and malabsorption
deficiencies common in clients with alcohol addiction.
A client with stage 2 Alzheimer’s disease is being cared for at home by the spouse.
The client’s spouse tells the nurse about the emotional difficulties involved in
providing fulltime care at home. Which self-care activity is most important for the
nurse to recommend to the spouse?
Periodic times of respite from caregiving.
Rationale:
Caregiver role strain may be attributed to many different factors. The nurse must
become familiar with this diagnosis in order to accurately assess the caregiver and
offer effective interventions. One important recommendation is to have the
caregiver incorporate periodic breaks as part of the daily routine to relieve stress.
The nurse should contact the client’s manager and provide the client’s caregiver a
list of agencies offering “Respite Care”.
The nurse is counseling a client who is dealing with complicated grief over the
death of a spouse. Which statement reflects the most desirable outcome for the
client?
The client will attend a surviving spousal support groups.
Rationale:
A major outcome of grief counseling is to assist the client in sharing their loss and
to accept support from others. It is critical for the spouse to share the feelings of
loss and grief in a supportive interpersonal environment. Complicated grief is a
consistent state of sadness associated with a great loss. It is suspected that there
may be a relationship between complicated grief and adjustment disorder. Most
people go through the stages of grief at their own pace. Individuals dealing with
complicated grief have difficulty progressing through the stages and it may take
over a year or more to resolve their sense of lost.
The nurse and the treatment team establish a weekly weight gain goal for a client
with anorexia nervosa. The client agrees to the goal, but continues to engage in
vigorous exercise before the weight gain goal has been met. Which statement by
the nurse is most effective in this situation?
“According to our agreement, no exercising is permitted until you have reached
your goal.”
Rationale:
Clients must be held accountable for behaviors that are not consistent with
treatment plan goals. The nurse is correct to remind client about the previously
established weight gain goals and to state that exercise should be limited (or not
permitted) until the weekly goal has been achieved.
Which behaviors indicate that the treatment plan for a client in alcohol
rehabilitation has been effective?
Abstinent 10 days; states that sobriety is to be accomplished one day at a time; has
spoken with employer about returning to work.
Rationale: The statement “one day at a time” reflects the Alcoholics Anonymous
(AA) philosophy. AA promotes a 12-step program that has been successful in
helping individuals who desire to stop drinking and abusing substances.
Individuals learn about sobriety and responsibility through the support of other
members.
A client is admitted due to alcohol intoxication and injuries sustained in a fall. The
client appears anxious, agitated, and diaphoretic. Vital signs include a pulse of 140
and a blood pressure of 170/98. Delirium is suspected due to the client’s claim that
bugs are crawling on the bed. Which medication should the nurse expect will be
administered to the client?
Chlordiazepoxide (Librium).
Rationale: The information provided indicates that the client is experiencing
alcohol withdrawal, and is therefore at an increased risk for seizures.
Chlordiazepoxide (Librium) raises the seizure threshold to reduce the risk of
convulsions.
A newly admitted client diagnosed with schizophrenia who is physically healthy
believes that they are in the process of dying and their body is actively decaying
and falling apart. Which intervention for this client should the nurse implement?
Discuss what they are feeling and acknowledge their fear and anxiety.
Rationale: The client’s delusion of dying and their body decaying is their reality.
The nurse should identify and focus on the client’s feelings and discuss those and
try to divert the client’s preoccupation of the delusion.
A client is undergoing treatment for schizophrenia. Which outcome provides
evidence that the client’s negative symptoms are improving?
Participates in music therapy and states that he enjoys playing the drums.
Rationale: An inability to experience pleasure and a desire to remain isolated are
examples of negative symptoms exhibited by clients with schizophrenia. By
participating in therapy and expressing enjoyment, the client shows a decrease in
negative symptoms and evidence that the treatment is being effective.
During a meeting with the interdisciplinary treatment team, a client in the acute
phase of schizophrenia states that she cannot return to live with her parents because
they are trying to kill her. Which statement by the team leader represents a correct
therapeutic response?
“That must be very frightening; tell us why you believe you are in danger.”
Rationale: The acute phase of illness is characterized by reality impairment and
paranoia; it is not useful to debate or contradict a delusion while a client is in the
acute phase. Attempting to see things from the client’s perspective will build trust,
which is the basis for an effective therapeutic relationship.
The emergency department nurse is providing care for a rape victim. Which action
represents an essential element of care for this client?
Providing nonjudgmental care.
Rationale: The nurse’s attitude can have an important therapeutic effect on the
victim of rape. Displays of shock, horror, disgust, or disbelief can increase anxiety
and shame. When providing care for a rape victim, it is essential to maintain a
nonjudgemental attitude, and to let the client talk while listening attentively
A newborn yellow abdomen and chest
Assess bilirubin level
A client delivers a viable infant, but begins to have excessive uncontrolled vaginal
bleeding after the IV Pitocin is infused. When notifying the healthcare provider of
the condition, what information is most important for the nurse to provide?
Maternal blood pressure
A 36-week primigravida is admitted to labor and delivery with severe abdominal
pain and bright red vaginal bleeding. Her abdomen is rigid and tender to touch.
The fetal heart rate (FHR) is 90 beats/minute, and the maternal heart rate is 120
beats/minute. What action should the nurse implement first?
obtain written consent for an emergency cesarean section
