A nurse in a long-term care unit is assisting in the care of a patient who has Alzheimer’s disease. What actions should the nurse take?
Participate in reminiscence therapy with the patient.
Raise the four side rails on the patient’s bed.
Alternate the patient’s daily routine.
Keep the lights dimmed.
The Correct Answer is A
Choice A rationale
Participating in reminiscence therapy can be beneficial for patients with Alzheimer’s disease. This therapy involves discussing past experiences and life events, which can help improve mood, enhance communication, and maintain self-identity.
Choice B rationale
Raising all four side rails on a patient’s bed is not recommended. This can be considered a form of restraint and can increase the risk of injury if the patient attempts to climb over the rails. It’s important to promote a safe environment while respecting the patient’s rights.
Choice C rationale
Alternating the patient’s daily routine can be confusing and disorienting for individuals with Alzheimer’s disease. Maintaining a consistent routine can provide a sense of security and predictability.
Choice D rationale
Keeping the lights dimmed is not specifically beneficial for patients with Alzheimer’s disease. Adequate lighting can help prevent falls and other accidents. However, creating a calm and quiet environment can help reduce agitation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
If 500 mL of fluid is removed during thoracentesis, the nurse should notify the provider. Removing large volumes of fluid can cause re-expansion pulmonary edema.
Choice B rationale
A clear chest x-ray is an expected finding after thoracentesis.
Choice C rationale
PCO2 is a measure of carbon dioxide levels in the blood. It is not directly related to thoracentesis.
Choice D rationale
Hematocrit is a measure of the proportion of red blood cells in the blood. It is not directly related to thoracentesis.
Correct Answer is D
Explanation
Choice D.
Choice A rationale
Diminished reflexes are a common finding in older adults due to the natural aging process of the nervous system and do not necessarily indicate a bladder infection.
Choice B rationale
A WBC count of 900/mm^3 is significantly lower than the normal range of 5000 to 16,000/mm^33. While this could indicate an issue with the immune system, it does not specifically point to a bladder infection.
Choice C rationale
A temperature of 33.9°C is lower than the average body temperature and does not suggest a bladder infection. Fever is a common symptom of infection, but hypothermia is not.
Choice D rationale
Altered mental status in an older adult client can be a sign of a urinary tract infection (UTI), including a bladder infection. UTIs in older adults can present with non-specific symptoms such as changes in mental status, making them harder to diagnose.
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