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.
Make a schedule of daily tasks.
Ask questions that require more than one answer.
Have several family members visit daily.
The Correct Answer is B
Explanation
B. Make a schedule for daily task.
Creating a schedule of daily tasks can provide structure and routine for individuals with Alzheimer's disease. This helps reduce confusion and frustration by providing a sense of familiarity and predictability. The schedule should be displayed in a visible location and include activities such as meals, personal care, medication administration, and any recreational or therapeutic activities. Following the schedule can help the client feel more oriented and decrease their frustration levels.
Limiting the use of familiar objects in (option A) should not be included because it may further increase frustration and disorientation. Familiar objects can provide comfort and a sense of security for individuals with Alzheimer's disease.
Asking questions that require more than one answer in (option C) should not be included because it can be overwhelming and confusing for someone with Alzheimer's disease. It is best to ask simple, straightforward questions to facilitate communication and comprehension.
Having several family members visit daily in (option D) should not be included because it may cause agitation and overstimulation for the client. It is important to maintain a calm and predictable environment, limiting the number of visitors and ensuring they are familiar to the client.
Therefore, the most appropriate intervention for the nurse to include is making a schedule of daily tasks (option B).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
An incident report is a tool used to document any unexpected or adverse event that occurs in the healthcare setting. It is important to report incidents to ensure proper investigation, analysis, and implementation of measures to prevent future occurrences.
In this example, the incident involves an error with an electronic IV pump resulting in the delivery of an incorrect amount of fluid, which can have serious implications for the client's safety and well-being.
The other examples listed may require further actions but may not necessarily require an incident report:
- A nurse discovers that a client's family member has administered a PCA dose: While it is concerning that a client's family member administered a patient-controlled analgesia (PCA) dose, it is more appropriate to address this situation through immediate intervention, education, and communication with the healthcare provider. An incident report may not be necessary unless there are further complications or system issues related to this incident.
- A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm: While the observation of improper restraint removal raises concerns about proper restraint protocol, it is more appropriate to address this situation through immediate intervention and communication with the involved nurse and healthcare provider. Depending on the severity of the situation, an incident report may or may not be warranted, but it is not the primary action in this case.
- A nurse observes a client vomiting after receiving an oral pain medication: While it is important to assess and address the client's condition and any adverse reactions, such as vomiting after receiving medication, it may not necessarily require an incident report. The nurse should assess the client, notify the healthcare provider, and document the incident appropriately in the client's medical record.
Correct Answer is D
Explanation
The priority is to address any significant changes in the child's behavior, such as withdrawal, as it may indicate emotional or psychological distress. Switching daycare providers can be a significant event for a young child, and it is essential to explore the reasons behind the child's withdrawal and address any potential underlying issues. The nurse should gather more information, assess the child's emotional well-being, and discuss any concerns or observations with the guardian. This will help identify appropriate interventions or support for the child's emotional adjustment.
While the other statements may also warrant attention, the potential emotional impact of the daycare provider change on the child's behavior and well-being takes priority in this case. The nurse should address the other concerns raised by the guardian during the assessment process, but the immediate focus should be on addressing the child's withdrawal and ensuring their emotional well-being.
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