A nurse is caring for a client who has late-stage Alzheimer's disease and is hospitalized for treatment of the flu. During the night shift, the client is found climbing into the bed of another client who becomes upset and scared. Which of the following actions should the nurse take?
Assist the client to the correct room.
Medicate the patient with antipsychotics.
Move the client to a room at the end of the hall.
Place the client in restraints.
The Correct Answer is A
Choice A rationale:
The nurse should prioritize the safety and well-being of both clients involved. Assisting the client with late-stage Alzheimer's disease to the correct room is important to prevent any further confusion or distress. Alzheimer's disease often causes cognitive impairment, memory loss, and disorientation, which can lead to situations where the individual may not recognize their surroundings or the people around them. Guiding the client back to their own room will help reduce confusion, agitation, and potential conflicts with other clients.
Choice B rationale:
Medicating the patient with antipsychotics is not the most appropriate initial action in this situation. Antipsychotic medications are often used to manage severe behavioral disturbances associated with conditions like schizophrenia or dementia, but their use should be carefully considered due to potential side effects. In this scenario, addressing the immediate situation and guiding the client back to their room is more appropriate than resorting to medication.
Choice C rationale:
Moving the client to a room at the end of the hall is not the best choice because it doesn't directly address the current situation. While changing the client's room might be considered in some cases to reduce agitation or wandering, it's not the immediate action needed when the client is found in another client's bed. Guiding the client to the correct room is the priority.
Choice D rationale:
Placing the client in restraints is not an appropriate choice in this situation. Restraints should only be used as a last resort for ensuring the safety of the client or others when less restrictive interventions have failed. Placing a client with Alzheimer's disease in restraints can be traumatic and lead to increased agitation and psychological distress.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice D rationale:
Setting limits on the client's behavior and maintaining consistency is essential when dealing with a client experiencing a manic episode. Manic episodes are characterized by impulsive and often disruptive behaviors. By setting clear limits, the nurse establishes boundaries that help manage the disruptive behavior and maintain a safe and therapeutic environment. Consistency in approach is vital to avoid confusion and to provide the client with a sense of stability during a time when their judgment and impulse control might be impaired.
Choice A rationale:
Warning the client that further disruptions will result in seclusion might escalate the situation and potentially worsen the client's agitation. It's crucial to use non-confrontational approaches when dealing with clients experiencing manic episodes to prevent increased agitation and aggression.
Choice B rationale:
Ignoring the client's behavior is not a suitable approach, as it could lead to a deterioration of the situation and potentially compromise the safety and well-being of both the client and others on the unit. It's important to address disruptive behavior promptly and appropriately.
Choice C rationale:
Asking the client to recommend consequences for her disruptive behavior might not be effective during a manic episode. Clients in a manic state might not have a realistic or rational perspective on their behavior, and involving them in determining consequences could lead to unreasonable outcomes.
Correct Answer is ["A","B","C","D"]
Explanation
The correct answer is: A, B, C, D.
Choice A reason: Shortening a reading activity when the child appears to become frustrated can help prevent the child from becoming overwhelmed and acting out. This is a common strategy used in managing children with conduct disorders.
Choice B reason: Introducing humor during interactions with the child can help build rapport and make the child feel more comfortable. It can also serve as a positive distraction and reduce tension.
Choice C reason: Redirecting with physical activities when the child’s disruptive behavior begins can serve as a healthy outlet for the child’s energy and frustrations. Physical activities can also help improve the child’s mood and reduce disruptive behaviors.
Choice D reason: Explaining to the child the importance of picking up crayons when thrown on the floor can help teach the child responsibility and respect for their environment. This can also be a part of behavioral therapy where the child learns about consequences of their actions.
Choice E reason: Placing the child in a vest restraint when disruptive behavior occurs is not recommended. Using physical restraints can be traumatizing and should only be used as a last resort when the child’s behavior poses a risk to themselves or others. It’s always better to use de-escalation techniques and positive reinforcement to manage disruptive behavior.
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