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

Hemoglobin and hematocrit

Liver function tests

Kidney function tests

Serum sodium and potassium

Answer and Explanation

The Correct Answer is D

A. Hemoglobin and hematocrit are important but not the focus in Alzheimer’s care unless anemia is suspected.

B. Liver function tests are not typically monitored unless the client is on hepatotoxic medications.

C. Kidney function tests are essential if there are concerns about hydration or medication clearance but are not routine in Alzheimer's care.

D. Monitoring serum sodium and potassium is critical as imbalances can lead to confusion, agitation, and worsening cognitive symptoms.

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Correct Answer is A

Explanation

A. Verbal de-escalation by acknowledging the client’s emotions (“You seem to be very upset”) helps to diffuse tension and can prevent further agitation.

B. Initiating seclusion should be a last resort after other de-escalation techniques fail.

C. Engaging the panic alarm is necessary only if the client becomes physically violent.

D. Using a face shield is not warranted unless there is a risk of bodily fluid exposure.

A. Place an ice pack on the client's perineum. B. Administer a benzodiazepine. C. Perform a fundal massage. D. Place the client's hands in warm water.

Correct Answer is B

Explanation

A. Sinus tachycardia: Incorrect. Sinus tachycardia shows a regular rhythm with identifiable P waves, not a wavy baseline.

B. Atrial fibrillation: The wavy baseline with no identifiable P waves and an irregular rhythm is characteristic of atrial fibrillation.

C. Second-degree heart block: Incorrect. Second-degree heart block shows a regular rhythm with some dropped QRS complexes, not a wavy baseline.

D. Ventricular asystole: Incorrect. Ventricular asystole shows no electrical activity, not a wavy baseline.

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

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