A home health nurse is assisting a family member with planning care for a client who has Alzheimer's disease. Which of the following instructions should the nurse include?
Remove clutter from rooms and hallways.
Place a monthly calendar in the client's room.
Use confrontation to manage the client's behavior.
Review the daily schedule with the client every morning.
The Correct Answer is A
Rationale:
A. Remove clutter from rooms and hallways: Keeping the environment free of clutter helps reduce confusion, prevents falls, and promotes safety for clients with Alzheimer’s disease, who often have impaired spatial awareness and judgment.
B. Place a monthly calendar in the client's room: A monthly calendar may be too complex and difficult for a client with Alzheimer's to interpret. Simpler tools, like a daily schedule or clock with the day and date, are more appropriate for supporting orientation.
C. Use confrontation to manage the client's behavior: Confrontation can increase agitation and confusion in clients with Alzheimer’s disease. A calm, supportive, and redirecting approach is more effective for managing difficult behaviors.
D. Review the daily schedule with the client every morning: While routine is beneficial, clients with moderate to severe Alzheimer’s may not retain or comprehend daily plans. Short, simple reminders throughout the day are often more effective than once-daily reviews.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Prepare to intubate the client with an endotracheal tube: Intubation is an invasive intervention typically reserved for clients with severe or rapidly deteriorating respiratory failure. It is not the first step in managing hypoxia when simpler oxygen delivery methods may be effective.
B. Place a nonrebreather face mask: This is the priority action because a nonrebreather mask delivers high-concentration oxygen (up to 95–100%) and can rapidly correct hypoxia. It is the most appropriate next step when a nasal cannula at 5 L/min is insufficient.
C. Obtain a prescription for arterial blood gases: While important for assessing the severity of hypoxia and guiding further treatment, this diagnostic action does not immediately address the client’s oxygenation needs.
D. Apply noninvasive positive-pressure ventilation: This intervention is beneficial for clients with certain conditions like COPD or heart failure but may not be the first-line response for general hypoxia. A nonrebreather mask is simpler and faster to apply in an acute setting.
Correct Answer is A
Explanation
Rationale:
A. Respiratory alkalosis: The pH is elevated at 7.48, and the PaCO₂ is decreased at 30 mm Hg, indicating a loss of carbon dioxide due to hyperventilation. The HCO₃ is within normal range, confirming the imbalance is respiratory in origin. This pattern reflects respiratory alkalosis, which is commonly caused by anxiety-induced hyperventilation.
B. Respiratory acidosis: Respiratory acidosis is characterized by low pH and elevated PaCO₂. In this case, the pH is high and PaCO₂ is low, which is the opposite pattern of respiratory acidosis.
C. Metabolic alkalosis: Metabolic alkalosis involves an elevated pH with an increased HCO₃. While this client’s pH is elevated, their HCO₃ is normal, making a metabolic cause unlikely.
D. Metabolic acidosis: Metabolic acidosis presents with a decreased pH and decreased HCO₃. The client’s pH is high and HCO₃ is within the normal range, ruling out this imbalance.
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