The nurse is working with a client who has hallucinations and ...

[leo leo]

The nurse is working with a client who has hallucinations and delusions. The client tells the nurse she can't take a shower because she's waiting for her husband to take her home.
 
  Which of the following responses by the nurse is best in this situation? A) It would be best if you just took your shower now.
  B) You seem anxious and upset.
  C) You have plenty of time to shower before it's time to go home.
  D) Why do you think you're going home?

Question 2

The nurse is assessing a client with early signs of dementia. The nurse asks the client what he ate for breakfast that morning. The purpose of this question is to determine which of the following?
 
  A) Orientation
  B) Food preferences
  C) Recent memory
  D) Remote memory

[kaillie]

Answer to Question 1

C
Feedback: This is an example of going along with rather than correcting the client's misperception, so that she can get on with her daily activities and not focus on being upset about not going home. Answers A, B, and D are not the best responses in this situation.

Answer to Question 2

C
Feedback: The initial sign of dementia is memory loss for recent events that exceeds normal forgetfulness. Asking what the client ate for breakfast is not determining orientation, food preferences, or remote memory.

[leo leo]

TYSM

[nyrave]

Gracias!