A nurse is caring for a patient with Alzheimer's Disease who falls frequently. Which of the following actions should the nurse take first to keep the patient safe?

Encourage the patient to ask for assistance.

Keep the call light near the patient.

Place the patient in a room close to the nurses' station.

Remind the patient to walk with someone for support.

Answer and Explanation

The Correct Answer is C

A. Encourage the patient to ask for assistance. – Patients with Alzheimer's often forget to ask for help, making this an unreliable safety measure.

B. Keep the call light near the patient. – The patient may not remember to use the call light.

C. Place the patient in a room close to the nurses' station. – Correct Answer. This allows frequent observation and quick intervention to prevent falls.

D. Remind the patient to walk with someone for support. – Reminders may not be effective due to memory impairment.

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Correct Answer is A

Explanation

A. Reflect on how she's feeling, and encourage her to express other fears that she has about his injury – Acknowledging emotions and encouraging open expression helps the mother process her grief and begin adjusting to the reality of the injury.

B. Explain that you aren't sure, but you will ask the physician to talk to her right away – Deferring to the physician misses an opportunity for emotional support.

C. Advise her that it isn’t in his best interest for her to be so upset, and explain the importance of moral support – This dismisses her emotions rather than addressing them.

D. Reassure her that given time and motivation he will return to normal function – Providing false reassurance is inappropriate, as a C5 spinal cord injury results in permanent loss of function.

A. Hct 45% B. Hgb 14.7 g/dL C. WBC 1,700/mm3 D. Platelets 160,000/mm3

Correct Answer is C

Explanation

A. Hct 45%. – Normal range for hematocrit (Hct) is 38-50%. No need to report.

B. Hgb 14.7 g/dL. – Normal range for hemoglobin (Hgb) is 13-17 g/dL. No need to report.

C. WBC 1,700/mm³. – Correct Answer. Normal WBC count is 4,000-11,000/mm³. A WBC count of 1,700/mm³ (neutropenia) places the patient at high risk for infection, requiring immediate intervention.

D. Platelets 160,000/mm³. – Normal range for platelets is 150,000-450,000/mm³. No need to report.

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