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A home health nurse is planning care for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?

Encourage physical activity prior to bedtime.

Replace the carpet with hardwood floors.

Wear clothing with zippers instead of buttons.

Place locks at the tops of exterior doors.

Answer and Explanation

The Correct Answer is D

A. Physical activity should be scheduled earlier in the day to prevent overstimulation and promote restful sleep.

B. Hardwood floors increase the risk of falls; carpets provide better traction and cushioning.

C. Zippers can be difficult for clients with Alzheimer's; clothing with Velcro or simple fasteners is preferred.

D. Placing locks at the tops of doors reduces the risk of wandering, a common safety concern in clients with Alzheimer's.

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Correct Answer is D

Explanation

A. Monitor vital signs every hour for the first 4 hr: Incorrect. Vital signs should be monitored more frequently, typically every 15 minutes during the first hour after administration, due to the risk of bleeding.

B. Administer medications intramuscularly: Incorrect. Intramuscular injections should be avoided while the client is on alteplase due to the increased risk of bleeding.

C. Provide a diet low in protein: Incorrect. There is no need for a low-protein diet with alteplase therapy. The focus should be on managing bleeding risks and monitoring for complications.

D. Observe for bruising of the skin: Alteplase is a thrombolytic medication, and one of its major side effects is bleeding. The nurse should monitor the client for signs of bruising, bleeding, or hemorrhage.

A. White flour tortillas B. Wheat crackers C. Potato pancakes D. Canned barley soup

Correct Answer is C

Explanation

A. White flour tortillas contain gluten and should be avoided.

B. Wheat crackers contain gluten and are inappropriate for celiac disease.

C. Potato pancakes are a gluten-free option and appropriate for a client with celiac disease, as they do not contain wheat, barley, or rye.

D. Barley soup contains gluten and is not safe for clients with celiac disease.

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A home health nurse is planning care for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?

Nursing Test Bank

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