A nurse is assisting with the plan of care for a client who has Alzheimer's disease. Which of the following actions should the nurse recommend for the plan of care?

Encourage the client to talk about current events.

Give directions using simple phrases.

Orient the client to time and place twice per day.

Rotate assistive personnel to help the client with ADLs.

Answer and Explanation

The Correct Answer is B

A.   Encouraging the client to talk about current events may not be effective, as individuals with Alzheimer's disease may have difficulty following complex conversations or remembering recent events.
B.   Giving directions using simple phrases is essential for effective communication with individuals who have Alzheimer's disease. Using clear, concise language helps reduce confusion and frustration and improves the client's ability to understand and follow instructions.
C.   Orienting the client to time and place twice per day can be helpful for some individuals with Alzheimer's disease, but the frequency and method of orientation may vary depending on the client's specific needs and preferences. It may not be necessary to orient the client twice per day in all cases.
D.   While it's important to provide consistent care to clients with Alzheimer's disease, rotating assistive personnel frequently may lead to confusion and distress for the client. Consistency and familiarity with caregivers can help establish trust and improve the client's sense of security.

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Correct Answer is A

Explanation

A. Elevating the client's legs before applying the stockings helps reduce venous stasis by promoting venous return and decreasing edema, which is essential for the effectiveness of the stockings.

B. Dorsiflexion of the feet can also aid in the application but is not as critical as elevation.

C. Massaging the legsis contraindicated as it may dislodge clots if present.

D.Folding the top of the stockings over can create a tourniquet effect and impede blood flow, which is harmful to the client.

A. Document urine color. B. Monitor the client for reports of bladder spasms. C. Check the drainage tubing for obstructions. D. Maintain the client in a left side-lying position. E. Use clean technique for intermittent irrigation.

Correct Answer is ["A","B","C","E"]

Explanation

A. Documenting urine color is essential after a transurethral resection of the prostate to monitor for bleeding and ensure that the bladder irrigation is effective in clearing out blood clots.
B. Monitoring for bladder spasms is important as they can indicate the presence of blood clots or other complications, and they can be very painful for the client.
C. Checking the drainage tubing for obstructions is crucial to maintain the patency of the catheter and ensure continuous irrigation. Obstructions can lead to complications such as bladder distention or increased bleeding.
D. Maintaining the client in a left side-lying position is not specifically required for continuous bladder irrigation and is not typically part of postoperative care for a client who had a transurethral resection of the prostate.
E. Using clean technique for intermittent irrigation is important to prevent infection. While sterile technique is ideal, clean technique can be used for the client's own catheter care at home or in settings where sterile technique is not feasible. However, in a clinical setting, sterile technique is usually preferred to minimize infection risk.

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A nurse is assisting with the plan of care for a client who has Alzheimer's disease. Which of the following actions should the nurse recommend for the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is observing an assistive personnel (AP) apply antiembolic stockings for a client. The nurse should identify that which of the following actions by the AP indicates an understanding of the procedure?

Correct Answer is A

Explanation

A nurse is caring for a client who had a transurethral resection of the prostate and now is receiving continuous bladder irrigation. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","B","C","E"]

Explanation

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