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 D
Explanation
A. A positive Romberg sign (difficulty maintaining balance with eyes closed) can indicate a neurological issue, but it is not directly associated with a migraine.
B. A subnormal temperature (low body temperature) is not typically associated with migraines and may indicate another issue, but it is not as concerning as other findings.
C. An ill college roommate might suggest a viral illness, but it is not a direct concern for the student’s migraine. Migraines are not contagious, and other signs of illness would be more concerning.
D. Positive Brudzinski sign, which involves involuntary flexion of the hips and knees when the neck is flexed, is indicative of meningeal irritation, a sign of meningitis. This is a medical emergency and much more concerning than the symptoms of a migraine. The student should be further assessed for signs of meningitis, which requires urgent treatment.
Correct Answer is A
Explanation
A. Providing a dark, quiet environment is an appropriate intervention for a client with a migraine headache. Migraines are often aggravated by bright lights and loud noises, so creating a calm, low-stimulation environment can help alleviate symptoms.
B. While caffeine can be a trigger for some individuals with migraines, it is not necessary to eliminate all caffeine. In fact, caffeine is sometimes included in medications for migraines to enhance their effectiveness.
C. Cognitive impairment is not a typical concern for migraines unless the headache is severe or prolonged. Monitoring for cognitive impairment would not be the primary action in this scenario.
D. Opioids are not recommended for the treatment of migraines due to their potential for abuse and side effects. NSAIDs, triptans, and other specific migraine treatments are preferred.
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