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 ["B","C","D","E"]
Explanation
Choice A reason: Adding the amount of bladder irrigation to the total output is incorrect. Instead, the nurse should subtract the amount of irrigation solution instilled from the total output to accurately measure the client's urine output.
Choice B reason: The correct answer is b because using sterile technique when preparing the irrigation solution is crucial to prevent introducing infections into the bladder or urinary tract during the continuous bladder irrigation process.
Choice C reason: The correct answer is c because ensuring the drainage tubing is patent and without obstruction is essential to maintain effective bladder irrigation and prevent complications such as bladder distention and clot formation.
Choice D reason: The correct answer is d because if the client reports a continual need to void, it may indicate that the irrigation is not functioning properly, and the surgeon should be contacted to assess the situation and make necessary adjustments.
Choice E reason: The correct answer is e because bright red urine or the presence of large clots can indicate active bleeding, which requires prompt notification of the surgeon for further evaluation and intervention.
Correct Answer is D
Explanation
Choice A reason: A dry raised rash is not a typical finding in scleroderma. Scleroderma primarily affects the skin and connective tissues, leading to hardening and tightening of the skin.
Choice B reason: Excessive salivation is not associated with scleroderma. Clients with scleroderma may experience dry mouth (xerostomia) instead.
Choice C reason: Periorbital edema is not a characteristic feature of scleroderma. Scleroderma involves systemic sclerosis that affects the skin, blood vessels, and internal organs.
Choice D reason: The correct answer is d because hardened skin is a hallmark of scleroderma. This autoimmune disease causes the skin to become thickened, tight, and stiff due to excessive collagen deposition.
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