during the evaluation of the quality of home care for a client with alzheimers disease the priority for the nurse is to reinforce which statement by a

NCLEX-RN

Exam Cram NCLEX RN Practice Questions

1. During the evaluation of the quality of home care for a client with Alzheimer’s disease, the priority for the nurse is to reinforce which statement by a family member?

A. “At least two (2) full meals a day are eaten.”
B. “We go to a group discussion every week at our community center.”
C. “We have safety bars installed in the bathroom and have 24-hour alarms on the doors.”
D. “The medication is not a problem to have taken three (3) times a day.”

Correct answer: “We have safety bars installed in the bathroom and have 24-hour alarms on the doors.”

Rationale: The correct answer is, '“We have safety bars installed in the bathroom and have 24-hour alarms on the doors.”' Ensuring the safety of a client with Alzheimer’s disease is crucial in home care. Installing safety features like bars in the bathroom and alarms on doors help prevent accidents and injuries. This contributes to creating a safe environment that promotes independence and autonomy for the client. Choices A, B, and D are incorrect because while they are important aspects of care, ensuring safety in the home environment takes precedence in caring for a client with Alzheimer’s disease.

2. Which of these is a correctly stated outcome goal written by the nurse?

A. The client will walk 2 miles daily by March 19
B. The client will understand how to give insulin by discharge
C. The client will regain their former state of health by April 1
D. The client achieve desired mobility by May 7

Correct answer: The client will walk 2 miles daily by March 19

Rationale: Outcome goals should be SMART, i.e., Specific, Measurable, Appropriate, Realistic, and Timely. Option A is the only outcome that has a specific behavior (walks daily), with measurable performance criteria (2 miles), and a time estimate for goal attainment (by March 19). Option B lacks specificity in terms of what 'understand how to give insulin' entails, and the timeline is vague ('by discharge'). Option C is not measurable or specific about what 'regain their former state of health' means. Option D does not provide a specific behavior or measurable criteria for 'desired mobility,' and the timeline is the only element that is time-bound.

3. Why should a palpated pressure be performed before auscultating blood pressure?

A. To more clearly hear the Korotkoff sounds.
B. To detect the presence of an auscultatory gap.
C. To avoid missing a falsely elevated blood pressure.
D. To more readily identify phase IV of the Korotkoff sounds.

Correct answer: To detect the presence of an auscultatory gap.

Rationale: Performing a palpated pressure before auscultating blood pressure helps in detecting the presence of an auscultatory gap. An auscultatory gap is a period during blood pressure measurement when Korotkoff sounds temporarily disappear before reappearing. Inflation of the cuff 20 to 30 mm Hg beyond the point where a palpated pulse disappears helps in identifying this gap. This technique ensures accurate blood pressure measurement by preventing the underestimation of blood pressure values. The other options are incorrect because palpating the pressure is not primarily done to hear Korotkoff sounds more clearly, avoid missing falsely elevated blood pressure, or readily identify a specific phase of Korotkoff sounds.

4. The most accurate reading for a temperature is done:

A. Orally
B. Aurally through a clean canal
C. Rectally
D. Axially

Correct answer: Aurally through a clean canal

Rationale: Aural readings are done through the ear canal. The tympanic membrane shares a blood supply with the hypothalamus, the brain area that regulates body temperature. Taking the temperature aurally through a clean canal ensures an accurate reading. Choice A (Orally) is not the most accurate method for temperature measurement as it can be affected by external factors like drinking hot or cold liquids. Choice C (Rectally) is invasive and less practical for routine temperature monitoring. Choice D (Axially) is not a standard method for temperature measurement and may not provide accurate results.

5. Which theory reflects the view that illness is caused by an imbalance or disharmony in the forces of nature?

A. Germ theory
B. Naturalistic theory
C. Magicoreligious theory
D. Biomedical or scientific theory

Correct answer: Naturalistic theory

Rationale: The naturalistic theory posits that illness results from an imbalance or disharmony in the forces of nature. According to this theory, maintaining a natural balance or harmony is essential to prevent illness. Conversely, germ theory and biomedical or scientific theory attribute illness to microorganisms, while magicoreligious theory attributes illness to supernatural forces such as deities or spirits. Therefore, the most appropriate theory reflecting the belief that illness arises from a disruption in natural forces is the naturalistic theory.