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?
Wear clothing with zippers instead of buttons.
Place locks at the tops of exterior doors.
Replace the carpet with hardwood floors.
Encourage physical activity prior to bedtime.
The Correct Answer is B
Choice A rationale:
Wearing clothing with zippers instead of buttons does not address the safety concerns related to Alzheimer's disease. This choice does not ensure the client's safety or prevent wandering, which are common issues in Alzheimer's patients.
Choice B rationale:
Placing locks at the tops of exterior doors is essential for the safety of clients with Alzheimer's disease. Alzheimer's patients often have a tendency to wander and may become disoriented, putting them at risk of getting lost or injured outside the home. Proper locks can prevent them from leaving the house unsupervised.
Choice C rationale:
Replacing the carpet with hardwood floors may reduce the risk of falls but does not specifically address the safety concerns related to Alzheimer's disease. It is important to focus on measures that prevent wandering and ensure the client's safety in various situations.
Choice D rationale:
Encouraging physical activity prior to bedtime is a good practice for promoting sleep in older adults but does not directly address the safety concerns of Alzheimer's patients. Safety measures, such as securing doors, supervising the client, and preventing wandering, are more crucial in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B) Speak in a neutral tone when addressing the client.
When creating a plan of care for a client with paranoid personality disorder who refuses to take their medication, it's essential to approach the client in a way that fosters trust and reduces anxiety. Speaking in a neutral, non-confrontational, and non-threatening tone can help build rapport and facilitate communication with the client.
The other options are not appropriate interventions:
A) Mixing medication with the client's food without their consent can be seen as a breach of trust and may worsen the client's paranoia.
C) Limiting the client's opportunities to socialize with others can lead to increased isolation and potentially exacerbate the client's paranoid tendencies.
D) Rotating staff members caring for the client may also contribute to feelings of mistrust and may not be conducive to establishing a therapeutic nurse-client relationship. Consistency in care can be more helpful for individuals with paranoid personality disorder.
Correct Answer is C
Explanation
Choice A rationale:
Upper extremity hypotension is not a common finding in coarctation of the aorta. Coarctation of the aorta typically results in narrowing of the aorta, leading to decreased blood flow to the lower part of the body. This can cause weak or absent femoral pulses and lower extremity hypotension, not upper extremity hypotension.
Choice B rationale:
Frequent nosebleeds are not directly associated with coarctation of the aorta. The symptoms of coarctation of the aorta are primarily related to decreased blood flow to the lower extremities, leading to symptoms such as weak femoral pulses, lower extremity hypotension, and leg cramping or pain.
Choice D rationale:
Increased intracranial pressure is not a typical finding in coarctation of the aorta. Coarctation of the aorta affects blood flow to the lower part of the body and does not directly impact intracranial pressure.
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