A home health nurse is assessing an older adult client whose sibling is the

A home health nurse is assessing an older adult

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A home health nurse is assessing an older adult client whose sibling is the primary caregiver. Which of the following findings should the nurse identify as a possible indicator of neglect?A) Increased confusionB) Sleep disturbancesC) Cluttered environmentD) Inappropriate dressAnswer: D Clothing that is soiled or clothing that is not appropriate for weather conditions is a possible indicator of neglect.While observing group therapy, a nurse recognizes that a client is behaving in a way suggestive of dependent personality disorder. Which of the following behaviors is consistent with this condition?A) The client needs excessive external input to make everyday decisions.B) The client demonstrates a dedication to his job that excludes time for leisure activities.
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C) The client adheres to a rigid set of rules.D) The client has difficulty starting new relationships unless he feels acceptedAnswer: A Client's who have dependent personality disorder need excessive input from others to make everyday decisions.During morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in her bed. The client reports that a bomb was placed in her room by a family member during visiting hours. Which of the following actions should the nurse take?A) Ask the client to identify the bomb in the room.B) Initiate disaster protocols per facility policies and procedures.C) Assess the client for evidence of perceptual disturbance.D) Convince the client that there is not bomb in her room.Answer: C The nurse should assess the situation to determine if the client is hallucinating or misperceiving external stimuli (experiencing illusions).A nurse is facilitating a community meeting for acute care clients. One client is constantly talking and using the majority of the groups time. Which of the following interventions should the nurse implement?A) Tell the client that he must talk less or he will be removed from the meeting.B) Ask group members to discuss their feelings about this client's monopolizing behavior.C) End the group meeting and take the client aside to discuss his behavior.D) Focus on other group members and ignore the client who is doing all the talking.Answer: B This intervention will validate other members' feelings toward the client who is dominating the meeting. It also should encourage group problem-solving.A nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects and kicking others. Which of the following therapeutic nursing interventions is the priority?A) Encourage expression of feelings.B) Promote attendance at an assertiveness training group.C) Assist the client to perform relaxation breathing.D) Use a therapeutic holding techniquesAnswer: D The greatest risk to the child and others is harm. Therefore, the nurse's priority intervention is to use a therapeutic holding technique to de-escalate the behavior and prevent injury.
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  • Fall '15
  • partner, Major depressive disorder

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