A nurse in a long-term care unit is assisting in the care of a client who has Alzheimer's disease. Which of the following actions should the nurse take?

Participate in reminiscence therapy with the client.

Raise the four side rails on the client's bed.

Alternate the client's daily routine.

Keep the lights dimmed.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A, participate in reminiscence therapy with the client. This is an effective intervention for individuals with Alzheimer's disease. It involves encouraging the client to discuss past experiences and events. It has been shown to improve mood, decrease agitation, and increase communication skills. The reminiscence therapy should be individualized and tailored to the client's interests and abilities.

Raising the four side rails on the client's bed is not the correct answer because this could cause harm to the client by restricting their mobility and independence.
Alternating the client's daily routine is not the correct answer because individuals with Alzheimer's disease benefit from a consistent routine, which helps them to feel more secure and less anxious.
Keeping the lights dimmed is not the correct answer because it can be disorienting and confusing for clients with Alzheimer's disease, who need adequate lighting to distinguish their surroundings.

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Correct Answer is ["A","D"]

Explanation

The correct answer is Choice A, Choice D.

Choice A rationale: Tachycardia, or an increased heart rate, is a common symptom of dehydration in infants. The body attempts to maintain adequate blood circulation despite reduced fluid volume by increasing the heart rate, which is a compensatory mechanism.

Choice B rationale: Bloating is not typically associated with dehydration in infants. Dehydration usually results in symptoms like dry mucous membranes and decreased skin turgor, rather than gastrointestinal symptoms like bloating.

Choice C rationale: Hypertension, or high blood pressure, is uncommon in dehydrated infants. Dehydration generally leads to hypotension (low blood pressure) due to decreased fluid volume in the circulatory system, which can result in reduced blood pressure.

Choice D rationale: Irritability is a frequent symptom of dehydration in infants. Reduced fluid intake and electrolyte imbalances can cause discomfort and distress, leading to irritability and increased fussiness in dehydrated infants.

A. Elevate the head of the client's bed for 1 hr after the feeding. B. Administer the feeding solution at a cold temperature. C. Rotate the jejunostomy tube once per day. D. Flush the tube with 90 mL of sterile water before and after the feeding.

Correct Answer is A

Explanation

The correct answer is choice A: Elevate the head of the client's bed for 1 hr after the feeding. This is because elevating the head of the client's bed to at least 30 degrees can help prevent aspiration and gastric reflux. Choice B is incorrect because administering the feeding solution at a cold temperature can cause discomfort and diarrhea. Choice C is incorrect because rotating the jejunostomy tube once per day can cause irritation and trauma to the stoma site. Choice D is incorrect because flushing the tube with 90 mL of sterile water before and after the feeding is not necessary as long as the tube is adequately flushed before and after each feeding.

Explanation for why the other choices are not answers: B – Administering the feeding solution at a cold temperature can cause discomfort and diarrhea, so it should not be done. C – Rotating the jejunostomy tube once per day can cause irritation and trauma to the stoma site, so this is not the correct action. D – Flushing the tube with 90 mL of sterile water before and after the feeding is unnecessary to do as long as the tube is adequately flushed before and after each feeding. Thus, this is not the correct answer.

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A nurse in a long-term care unit is assisting in the care of a client who has Alzheimer's disease. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following symptoms should a nurse expect to find when assessing an infant who is dehydrated in an emergency department? Select all that apply

Correct Answer is ["A","D"]

Explanation

A nurse is caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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