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. Obtain the patient's blood glucose level between 2a.m-4a.m – Correct Answer. The Somogyi effect occurs when nighttime hypoglycemia triggers a rebound hyperglycemia in the morning. Checking the blood glucose level during the early morning hours helps confirm this phenomenon.

B. Check the patient for a change in level of consciousness between 2a.m-4a.m – Incorrect. While severe hypoglycemia can affect consciousness, the best way to confirm the Somogyi effect is through blood glucose monitoring.

C. Withhold the nighttime snack and check the glucose at 6:00 a.m. – Incorrect. A nighttime snack can help prevent the hypoglycemia that leads to the Somogyi effect.

D. Administer an increased dose of NPH insulin in the evening. – Incorrect. Increasing insulin could worsen nighttime hypoglycemia, making the Somogyi effect worse.

A. Eat plenty of fresh fruits and vegetables. B. Take temperature weekly. C. Perform mild exercise, such as gardening. D. Avoid crowds.

Correct Answer is D

Explanation

A. Eat plenty of fresh fruits and vegetables. – Incorrect. Raw fruits and vegetables can harbor bacteria, increasing the risk of infection for a patient with neutropenia.

B. Take temperature weekly. – Incorrect. Patients with neutropenia should check their temperature daily, as fever may be the first sign of infection.

C. Perform mild exercise, such as gardening. – Incorrect. Gardening exposes the patient to soilborne fungi and bacteria, which can be harmful.

D. Avoid crowds. – Correct Answer. Neutropenic patients are highly susceptible to infections, so avoiding crowds helps reduce the risk of exposure to contagious illnesses.

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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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