A nurse is caring for a client who has Alzheimer's disease and is confused. Which of the following actions should the nurse take?
Keep the television on at all times.
Hang abstract pictures on the walls.
Keep familiar personal items in the client's room.
Encourage bright lighting in the room.
The Correct Answer is C
Choice A reason: Keeping the television on at all times can contribute to overstimulation and confusion for clients with Alzheimer's disease. It is better to have the television on at specific times and choose calming, familiar programs.
Choice B reason: Hanging abstract pictures on the walls can be confusing and disorienting for clients with Alzheimer's disease. Simple, familiar images or family photographs are more helpful in creating a comforting environment.
Choice C reason: The correct answer is c because keeping familiar personal items in the client's room can provide a sense of security and comfort. Familiar objects can help reduce confusion and anxiety in clients with Alzheimer's disease.
Choice D reason: While adequate lighting is important, bright lighting can sometimes cause discomfort or glare. It is better to have soft, consistent lighting that helps the client feel safe and oriented without causing overstimulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Emptying the collection chamber every 4 hours is unnecessary and can increase the risk of introducing infection. The chamber should be emptied as needed based on the volume of drainage.
Choice B reason: Stripping the chest tube, which involves squeezing and releasing sections of the tube to move clots, is not recommended as it can create high negative pressure and cause damage to the lung tissue.
Choice C reason: Pinning the chest tube to the client’s gown can lead to accidental dislodgement. The chest tube should be secured appropriately without tension.
Choice D reason: The correct answer is d because taping the connections on the client’s chest tube ensures that the system remains airtight and prevents air leaks, which is essential for effective functioning of the chest tube and prevention of pneumothorax recurrence.
Correct Answer is D
Explanation
Choice A reason: An apical pulse rate different than the radial pulse rate is known as a pulse deficit, which can indicate atrial fibrillation or other cardiac arrhythmias, but it is not related to paradoxical blood pressure or constrictive pericarditis.
Choice B reason: An increase in heart rate by 20% when standing is indicative of orthostatic hypotension, not paradoxical blood pressure. This condition involves a drop in blood pressure upon standing, leading to a compensatory increase in heart rate.
Choice C reason: A drop in systolic BP by 20 mm Hg when moving from a lying to a sitting position is another indicator of orthostatic hypotension, not paradoxical blood pressure.
Choice D reason: The correct answer is d because a drop in systolic BP of more than 10 mm Hg on inspiration, known as pulsus paradoxus, is a characteristic finding in constrictive pericarditis. This occurs due to the impaired filling of the heart during inspiration, leading to a significant drop in systolic blood pressure.
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