A nurse is caring for a client who has Alzheimer's disease. The nurse discovers the client entering the room of another client, who becomes upset and frightened. Which of the following actions should the nurse take?
Attempt to determine what the client was looking for.
Reprimand the client for invading the other client's privacy.
Explain the client's Alzheimer's diagnosis to the frightened client.
Ask the client to apologize for his behavior.
The Correct Answer is A
A. Attempt to determine what the client was looking for is the best response. In Alzheimer's disease, clients may exhibit wandering behavior and confusion, often seeking something familiar or trying to meet an unmet need. Understanding what the client was looking for can help address their needs and prevent further agitation.
B. Reprimanding the client for invading the other client's privacy is not appropriate. Clients with Alzheimer's disease may not be aware of the concept of privacy or the impact of their actions. Reprimanding can cause distress and confusion.
C. Explaining the client's Alzheimer's diagnosis to the frightened client may help provide understanding, but it does not address the immediate concern of calming the frightened client. The focus should be on managing the behavior in the moment.
D. Asking the client to apologize for his behavior is not appropriate, as the client may not have the cognitive ability to understand or remember the need to apologize. This could cause frustration and confusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A cervical collar is not necessary for a lumbar laminectomy. A cervical collar is used for neck surgeries or spinal cord injuries involving the cervical spine, not for lumbar procedures.
B. The head of the bed elevated 30 degrees may be appropriate for certain conditions, but after a lumbar laminectomy, it is typically recommended to keep the head of the bed flat or slightly elevated to reduce pressure on the spine.
C. Logrolling the client every 2 hr is the correct action. After a lumbar laminectomy, the nurse should use the logroll technique to turn the patient to prevent strain on the spine and promote proper healing.
D. Supine with her arms elevated on pillows is not the best position. While elevation of the arms may be helpful for comfort, the focus should be on protecting the lumbar spine and ensuring proper positioning to prevent strain.
Correct Answer is B
Explanation
A. A blood pressure cuff is not directly needed to assess neurological status. While blood pressure is important to monitor in neurological assessments, it is not the primary tool used for assessing neurological function.
B. A pen light is essential for assessing pupil reaction, which is a key part of a neurological exam. The nurse can use the pen light to check for pupil dilation, constriction, and reaction to light, which are important indicators of brain function.
C. A thermometer is useful for measuring body temperature but is not a primary tool for assessing neurological status. Although fever can be a sign of infection affecting the brain, it is not part of the basic neurological exam.
D. A stethoscope is useful for listening to heart and lung sounds, but it is not typically used for assessing neurological function. The pen light is the more appropriate tool for this purpose.
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