A nurse is caring for a client who has early-stage Alzheimer's disease. In which of the following actions is the nurse acting as a client advocate?
Requesting a referral for the client to attend reminiscence therapy sessions
Performing an updated cognitive assessment on the client
Providing assistance for the client when ambulating down the hall
Reorienting the client several times throughout the day
The Correct Answer is A
Choice A reason: Reminiscence therapy is a type of intervention that helps clients with Alzheimer's disease recall and share their past experiences, memories, and emotions. This can enhance their self-esteem, mood, and quality of life. By requesting a referral for this therapy, the nurse is advocating for the client's psychosocial needs and preferences.
Choice B reason: Performing an updated cognitive assessment on the client is not an example of advocacy, but rather a standard nursing practice. Cognitive assessments are used to monitor the client's cognitive status and progression of the disease. They do not necessarily reflect the client's wishes or interests.
Choice C reason: Providing assistance for the client when ambulating down the hall is not an example of advocacy, but rather a safety measure. The nurse is helping the client prevent falls and injuries, which are common risks for clients with Alzheimer's disease. This does not imply that the nurse is speaking up for the client or protecting their rights.
Choice D reason: Reorienting the client several times throughout the day is not an example of advocacy, but rather a therapeutic communication technique. The nurse is helping the client cope with confusion and disorientation, which are common symptoms of Alzheimer's disease. This does not indicate that the nurse is supporting the client's goals or values.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: An aPTT (activated partial thromboplastin time) of 34 seconds is within the therapeutic range for heparin therapy. There is no immediate need for an interdisciplinary conference based solely on this result. The nurse can continue monitoring the client's aPTT and adjust heparin dosing as needed. The aPTT value is appropriate for the client's condition, and no urgent intervention is required.
Choice B reason: Insulin pump management primarily involves coordination between the patient and the diabetes care team. While education and ongoing support are essential, an interdisciplinary conference is not typically necessary for routine insulin pump use. Insulin pump management is a well-established process that does not require immediate collaboration among multiple disciplines.
Choice C reason: Orthostatic hypotension is a condition where blood pressure drops significantly upon standing. IV fluids are commonly used to manage orthostatic hypotension by increasing blood volume and improving blood pressure regulation. An interdisciplinary conference would involve collaboration among healthcare professionals to address the client's specific needs related to orthostatic hypotension, fluid management, and prevention of complications. Orthostatic hypotension requires coordinated efforts from various disciplines to optimize care.
Choice D reason: While albumin levels are relevant for assessing nutritional status and wound healing, this specific scenario does not necessitate an interdisciplinary conference. Pressure ulcer prevention and management can be addressed through routine nursing assessments and interventions. Pressure ulcer risk and albumin levels can be managed within the nursing scope without immediate interdisciplinary collaboration.
Correct Answer is D
Explanation
Choice A reason: While it's essential to use a fire extinguisher during a fire emergency, aiming at the top of the flames is not the correct technique. Fire extinguishers should be aimed at the base of the flames to cut off the oxygen supply and extinguish the fire effectively.
Choice B reason: During a fire, moving client care equipment into the hallway is not recommended. In an emergency, the priority is to ensure the safety of patients and staff. Moving equipment might obstruct evacuation routes or delay the evacuation process.
Choice C reason: This choice is incorrect. Placing dry towels at the base of doors is not a recommended action during a fire. It does not effectively prevent smoke or fire from spreading. Instead, use proper fire-rated door seals or close the doors securely to prevent smoke and flames from entering rooms.
Choice D reason: Closing the windows in client rooms is a correct action during a fire. Closed windows help prevent the entry of smoke and flames, reducing the risk to patients and staff. It also helps maintain a safe environment within the room.
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