A nurse is caring for a patient with middle stage Alzheimer's disease. Which of the following actions by the nurse may benefit the patient?
Provide puzzles for the patient and family during visits.
Keep lights on at all times.
Turn the volume up on the television in the client's room.
Keep familiar personal items at the bedside.
The Correct Answer is D
Choice D rationale
Middle-stage Alzheimer's disease is characterized by increasing confusion, memory loss, and disorientation. Keeping familiar personal items at the bedside, such as family photographs or a favorite blanket, provides a sense of security and helps orient the patient to their identity. These "anchors" can reduce anxiety and "sundowning" behaviors by making the environment feel less clinical and more recognizable. This approach supports the patient's emotional well-being and helps maintain a connection to their past.
Choice A rationale
While providing activities is generally good, complex puzzles may be frustrating for a patient in the middle stage of Alzheimer's. At this stage, cognitive deficits often impair problem-solving skills and fine motor coordination. If a task is too difficult, it can lead to agitation and a sense of failure. The nurse should instead suggest simpler, failure-free activities that focus on sensory engagement or repetitive motions rather than complex cognitive challenges that require high levels of concentration.
Choice B rationale
Keeping lights on at all times is counterproductive and can disrupt the patient's circadian rhythm. Sleep-wake cycle disturbances are common in Alzheimer's patients, and constant light can lead to sleep deprivation and increased delirium. The environment should be bright during the day to encourage alertness and dimmed at night to signal that it is time for rest. Maintaining a natural light cycle is essential for reducing confusion and managing the behavioral symptoms of the disease.
Choice C rationale
Increasing the volume on the television can create an environment of sensory overload. Patients with Alzheimer's often have difficulty processing multiple or loud stimuli, which can lead to agitation, fear, or "noise-induced" confusion. A calm, quiet environment is generally preferred to minimize triggers for behavioral outbursts. The nurse should ensure that noise levels are kept at a comfortable, low level to promote a soothing atmosphere and help the patient remain calm and focused.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["700"]
Explanation
Step 1 is 0.7 g × 1000 mg/g. Final calculated answer is 700 mg.
Correct Answer is D
Explanation
Choice A rationale
Phosphate levels are generally not the primary concern when administering loop diuretics like furosemide. While diuretics can affect various electrolytes, the most significant life-threatening imbalances caused by furosemide involve potassium and sodium. Normal serum phosphate ranges from 3.0 to 4.5 mg/dL. While it is important to monitor overall metabolic status in heart failure patients, phosphate does not have the same immediate impact on cardiac rhythm and muscle function as potassium does during diuretic therapy.
Choice B rationale
Carbon dioxide levels in a metabolic panel reflect the bicarbonate concentration and the acid-base balance of the blood. While loop diuretics can cause metabolic alkalosis, which would increase these levels, it is not the most critical parameter to check before a single dose. Normal venous carbon dioxide levels range from 23 to 30 mEq/L. The priority is to assess for electrolyte deficiencies that could cause immediate cardiac complications, making potassium a more vital laboratory value to review.
Choice C rationale
Bicarbonate levels are an indicator of the body's acid-base status. Furosemide can lead to contraction alkalosis, causing an increase in bicarbonate levels over time. Normal bicarbonate levels range from 22 to 28 mEq/L. While monitoring for alkalosis is part of long-term care for clients on diuretics, it is not the priority assessment before drug administration. The nurse must prioritize electrolytes that directly influence heart rate and rhythm in the context of heart failure and loop diuretic use.
Choice D rationale
Furosemide is a loop diuretic that inhibits the reabsorption of sodium, chloride, and water in the ascending limb of the loop of Henle, leading to increased excretion of potassium. Normal serum potassium levels are 3.5 to 5.0 mEq/L. Administering furosemide to a client with hypokalemia can lead to life-threatening cardiac arrhythmias. Because heart failure patients often take other medications like digoxin, low potassium significantly increases the risk of toxicity and must be verified before administration.
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