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 A
Explanation
Rationale:
A. Report of itching: Itching is a common early sign of an allergic transfusion reaction. These reactions occur due to sensitivity to plasma proteins in the donor blood and may also present with hives, flushing, or mild respiratory symptoms.
B. Distended jugular veins: Jugular vein distention is a sign of fluid overload or circulatory compromise, such as transfusion-associated circulatory overload (TACO), not an allergic reaction.
C. Report of low back pain: Low back pain is more indicative of an acute hemolytic reaction, which results from ABO incompatibility. This is a serious and life-threatening reaction distinct from allergic responses.
D. Temperature 37.8° C (100° F): A mild elevation in temperature may be seen with febrile non-hemolytic transfusion reactions, which are different from allergic reactions. Allergic reactions usually involve skin and respiratory symptoms.
Correct Answer is {"A":{"answers":"A,C"},"B":{"answers":"A,C"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A,C"},"G":{"answers":"B"}}
Explanation
Rationale:
- Location of pain: Severe pain out of proportion to the injury, especially with passive stretch, is a classic sign of compartment syndrome. DVT also presents with localized pain in the affected limb, typically worsening over time due to venous congestion.
- Temperature of extremity (Compartment Syndrome & DVT): A cool extremity in compartment syndrome indicates compromised arterial blood flow due to increased pressure within the fascial compartment. In DVT, the extremity may be warm early on, but impaired circulation can eventually result in coolness and cyanosis.
- Nail bed assessment (Compartment Syndrome): Cyanotic or dusky nail beds reflect inadequate oxygen delivery from restricted blood flow, commonly seen in advanced compartment syndrome. This is a late and critical sign requiring urgent intervention to prevent permanent tissue damage.
- Location of edema (Compartment Syndrome & DVT): Localized swelling occurs in compartment syndrome due to rising intracompartmental pressure. In DVT, venous obstruction leads to fluid accumulation and unilateral leg edema, often accompanied by warmth and discomfort.
- Respiratory assessment (Fat Embolism Syndrome): FES often presents with sudden onset dyspnea, tachypnea, and hypoxemia due to fat globules entering the pulmonary circulation. These respiratory symptoms typically arise 24–72 hours after long bone trauma.
- Skin assessment (Fat Embolism Syndrome): A petechial rash, especially on the chest, upper arms, and neck, is a distinguishing feature of FES. It results from occlusion of dermal capillaries by fat globules and is considered a hallmark sign of the condition.
- Neurological status (Fat Embolism Syndrome): Altered mental status, confusion, and decreased alertness can occur in FES due to cerebral fat embolization. Neurologic involvement differentiates FES from other conditions like DVT or compartment syndrome, which typically do not cause cognitive changes.
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