A home health nurse is caring for a client who has Alzheimer's disease. The client's son is concerned about his mother becoming frustrated. Which of the following interventions should the nurse include?

Limit the use of familiar objects.

Ask questions that require more than one answer.

Make a schedule of daily tasks.

Have several family members visit daily.

Answer and Explanation

The Correct Answer is C

Creating a schedule of daily tasks can help provide structure and routine for individuals with Alzheimer's disease. Having a predictable routine can reduce confusion and frustration by providing a sense of familiarity and stability. The schedule should include activities that the client enjoys and can manage within their abilities. It can help the client feel more organized and engaged throughout the day.

Limiting the use of familiar objects is not recommended. Familiar objects can provide comfort and a sense of security for individuals with Alzheimer's disease. They can help trigger memories and create a sense of familiarity in their environment. Removing familiar objects may increase disorientation and frustration.

Asking questions that require more than one answer can be overwhelming for individuals with Alzheimer's disease. Complex questions can lead to confusion and frustration as the person may struggle to recall or process information. It is best to ask simple and direct questions that can be easily understood and answered.

Having several family members visit daily may cause additional stress and confusion for the client with Alzheimer's disease. Too many visitors can be overwhelming and may disrupt the person's routine or environment. It is important to consider the individual's preferences and abilities when planning visits and ensure that they are manageable and supportive for the client's well-being.

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Correct Answer is A

Explanation

A.Emptying the ostomy pouch before removing the skin barrier reduces the risk of spillage and makes the procedure less messy. It is also more comfortable for the client and helps prevent leakage of stool onto the skin, which can cause irritation.

B. It’s generally recommended to change an ostomy appliance when the bowel is least active, such as before meals or several hours after eating. Changing it one hour after breakfast may coincide with increased bowel activity, which can increase the risk of leakage and make the change more challenging.

C.Moisturizing soaps should be avoided when cleaning the skin around the stoma because they can leave a residue that interferes with the adhesion of the skin barrier, potentially leading to leakage. The nurse should use a mild, non-moisturizing soap or just water to clean the area to ensure proper adhesion of the appliance.

D.The opening on the skin barrier should closely match the size of the stoma, with a slight gap of about 1/8 inch (0.3 cm) around it to avoid pressure on the stoma while also protecting the surrounding skin. Creating an opening that is 0.5 inches (1.27 cm) larger than the stoma would leave too much skin exposed, increasing the risk of irritation and infection.

A. Assists the client to the bathroom every 2 hr B. Locks the wheels on the client's bed C. Raises all four side rails on the client's bed D. Clears furniture from the path leading to the bathroom

Correct Answer is C

Explanation

A. Assisting the client to the bathroom at regular intervals helps prevent falls due to toileting needs.

B. Locking the wheels on the bed prevents unwanted movement and reduces the risk of falls when the client is in bed.

C. Raising all four side rails is considered a restraint, which can increase the risk of falls or injury if the client tries to climb over them. Restraints should be avoided unless absolutely necessary and prescribed by a healthcare provider. In most cases, raising two side rails is sufficient to prevent the client from accidentally rolling out of bed while allowing them to safely exit the bed.

D. Clearing the path from obstacles and furniture reduces the risk of falls by providing a safe and unobstructed route to the bathroom.

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A home health nurse is caring for a client who has Alzheimer's disease. The client's son is concerned about his mother becoming frustrated. Which of the following interventions should the nurse include?

Nursing Test Bank

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