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
A. Asthma: Asthma affects the respiratory system and does not have a direct link to urinary tract infections. It does not alter urinary tract anatomy or immune defenses specific to the urinary system.
B. Diabetes mellitus: Clients with diabetes are at increased risk for UTIs due to immune suppression, glucosuria that promotes bacterial growth, and possible bladder dysfunction (e.g., urinary retention) from diabetic neuropathy. Poor glycemic control further raises infection susceptibility.
C. Pernicious anemia: This condition is related to vitamin B12 deficiency and affects red blood cell production and neurological function, but it does not specifically predispose clients to UTIs.
D. Osteoporosis: Osteoporosis involves reduced bone density and is not associated with urinary tract infections. It does not impact the urinary or immune systems directly.
Correct Answer is B
Explanation
Rationale:
A. The stool will have a tarry color: Tarry stools typically indicate the presence of digested blood from upper gastrointestinal bleeding. This is not expected after an ileostomy, which involves the small intestine, not the upper GI tract.
B. The stool will have a high volume of liquid: After a colectomy with ileostomy placement, stool bypasses the colon, where most water reabsorption occurs. As a result, the output from an ileostomy is typically frequent and liquid or semi-liquid in consistency.
C. The stool will be solid and well-formed: Solid, well-formed stools are characteristic of a functioning colon. Because the colon is removed in a colectomy with ileostomy, stool will not be solid due to the lack of water absorption.
D. The stool will appear bloody with clots: Bloody stools with clots suggest active bleeding, which is not expected in normal postoperative ileostomy output. This would be an abnormal finding and should be reported immediately.
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