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. Alert and oriented, blood and urine without ketones, no orthostatic blood pressure changes – These findings indicate improved hydration, resolution of hyperosmolarity, and recovery of neurological function, key markers of HHS improvement.

B. Alert and oriented, balanced intake and output, moist mucous membranes – While improved hydration is good, ketone clearance and hemodynamic stability are more important indicators.

C. Respirations easy and unlabored, eats 50-75% of meals, vital signs stable – Respiratory status is not the primary concern in HHS.

D. Equal intake and output, denies pain or shortness of breath – These signs do not specifically indicate resolution of HHS.

A. Tachycardia and hypertension B. Bradycardia and hypertension C. Bradycardia and hypotension D. Tachycardia and hypotension

Correct Answer is B

Explanation

A. Tachycardia does not occur with autonomic dysreflexia.

B. Autonomic dysreflexia is a life-threatening condition caused by a noxious stimulus (e.g., full bladder, constipation) in patients with spinal cord injuries above T6. It leads to severe hypertension and reflex bradycardia.

C. Hypotension is not a symptom; autonomic dysreflexia causes hypertension.

D. Tachycardia and hypotension are more associated with spinal shock rather than autonomic dysreflexia.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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