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. Check the patient’s blood temperature. – Correct Answer. A headache and stiff neck are classic signs of meningitis. Fever is another key symptom, so checking temperature helps confirm suspicion and guides urgent intervention.

B. Administer an oral analgesic. – Incorrect. Pain management is secondary. The priority is assessing for infection (meningitis).

C. Perform a complete blood count. – Incorrect. While a CBC may show elevated WBCs, immediate assessment is more urgent.

D. Evaluate the patient’s neurological status. – Incorrect. While neurological assessment is important, confirming fever as an infection indicator is the first step.

A. Dextrose 5% in 0,45% sodium chloride IV B. Oral hypoglycemic medications C. Glucocorticoid medications D. 0.9% sodium chloride IV

Correct Answer is D

Explanation

A. Dextrose 5% in 0.45% sodium chloride IV. – Incorrect. Dextrose is given later, after blood glucose drops below 250 mg/dL to prevent hypoglycemia.

B. Oral hypoglycemic medications. – Incorrect. DKA requires IV insulin, not oral medications.

C. Glucocorticoid medications. – Incorrect. Glucocorticoids can worsen hyperglycemia by increasing blood sugar.

D. 0.9% sodium chloride IV. – Correct Answer. Fluid resuscitation with normal saline is the first priority to correct hypovolemia caused by osmotic diuresis in DKA.

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