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.

Answer and Explanation

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.

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

Explanation

Choice A reason: Osteoarthritis is a degenerative joint disease and is not associated with SIADH. It does not typically affect the body's regulation of antidiuretic hormone (ADH) or fluid balance.

Choice B reason: Lung cancer, particularly small cell lung cancer, is a common cause of SIADH. Tumor cells can produce and secrete ADH, leading to inappropriate water retention and hyponatremia. Therefore, asking about lung cancer history is important in the assessment.

Choice C reason: The correct answer is c because liver cirrhosis can lead to secondary conditions that may affect fluid balance and ADH secretion. Although not a direct cause of SIADH, liver dysfunction can complicate the clinical picture and contribute to fluid retention issues.

Choice D reason: Dyspepsia, or indigestion, is not related to SIADH and does not typically impact ADH regulation. It is a gastrointestinal issue that does not affect fluid balance.

Choice E reason: The correct answer is e because seizures can be associated with conditions that trigger SIADH. Neurological disorders, including brain injuries and infections, can lead to the inappropriate release of ADH, resulting in fluid retention and hyponatremia.

A. A client who has a splinted open fracture of the left medial malleolus. B. A client who has a penetrating head injury and is experiencing seizures. C. A client who has severe respiratory stridor and a deviated trachea. D. A client who has a small circular partial-thickness burn of the left calf.

Correct Answer is C

Explanation

Choice A reason: An open fracture, while needing medical attention, is not immediately life-threatening. The client's condition is stable enough to wait while more critical cases are attended to.

Choice B reason: A penetrating head injury with seizures is a critical condition. However, ensuring a patent airway takes precedence in emergency situations. This client's seizures indicate serious brain injury, but the immediate threat to life, such as airway obstruction, must be prioritized.

Choice C reason: Severe respiratory stridor and a deviated trachea indicate a life-threatening airway obstruction. This client needs immediate attention to secure the airway and prevent respiratory failure. This is the highest priority because without a clear airway, the client will not survive long enough to benefit from other interventions.

Choice D reason: A partial-thickness burn, although painful and requiring treatment, is not immediately life-threatening. This client can safely wait while those with more critical needs are attended to.

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A nurse is caring for a client who has Alzheimer's disease and is confused. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client. The provider suspects the client may have the syndrome of inappropriate antidiuretic hormone (SIADH). When obtaining a medical history, the nurse should ask for additional information about which of the following conditions? (Select all that apply.)

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

Explanation

A nurse is assisting with triaging clients after a mass casualty event. Which of the following clients should the nurse attend to first?

Correct Answer is C

Explanation

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