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 C
Explanation
Choice A reason: Serosanguineous drainage from the puncture site is an expected finding after a thoracentesis and does not typically indicate a complication.
Choice B reason: Discomfort at the puncture site is common following a thoracentesis and does not necessarily indicate a complication.
Choice C reason: The correct answer is c because an increased heart rate can be a sign of respiratory distress or hypovolemia, which are potential complications of a thoracentesis. This finding warrants immediate notification of the provider.
Choice D reason: A decreased temperature is not a common complication of thoracentesis and is less relevant than the other options. It is more important to monitor for signs of respiratory distress or circulatory changes.
Correct Answer is D
Explanation
Choice A reason: Reviewing relaxation techniques can be beneficial for managing anxiety during an asthma attack, but it is not the highest priority in an acute situation.
Choice B reason: Providing immediate rest can help the client conserve energy and reduce the work of breathing, but it does not address the underlying cause of the asthma exacerbation.
Choice C reason: Reminding the client not to try to talk helps reduce the work of breathing, but it is not the most urgent intervention.
Choice D reason: The correct answer is d because administering a short-acting beta-adrenergic medication, such as albuterol, is the highest priority. These medications act quickly to relax the bronchial muscles, reduce bronchospasm, and improve airflow, which is critical in an acute asthma exacerbation.
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